Unbundling the Hospital Repackaging Community Wellness

by Christopher Becker
Dening Wellness
What comes to mind when you consider
wellness? For some wellness is simply
being free from physical sickness. For
others, wellness is made up of a whole
range of self centering principles.
Often, we think of wellness as an indi-
vidual goal, but actually wellness is as
much a collaborative aspiration as it
is a singular one. We want to see our
family well, our community well, and our
city well. In this light it is clear wellness is
more than medical treatment or physi-
cal tness. Wellness includes our social
roles and obligations and as such, we all
play an important role in the wellness of
others.
We may know how to keep ourselves
well, even if we are not always good
practitioners. But how do we go about
keeping our families, community, and
city well? Designers have excellent
potential to contribute to the concept
of wellness at these scales.
In a unique way the hospital building
typies the attitudes and sensitivities of
our culture. Hospitals have historically
been founded as philanthropic ges-
tures in response to often overwhelming
needs of the community.
The Ospedale degli Innocenti was com-
missioned in 1419 to address the needs
of a community in crisis where land and
inheritance prerogatives were producing
an unfortunate number of abandoned
children needing care
1
. The situation of
the hospital within the city of Florence is a
memorable example of an architectural
design that involves the community in the
process of wellness.
Returning to Wellness
In the last century, with increasing de-
mand and interest in healthy populations,
western industrialized countries began to
expand hospital programs. Rapid growth
in medical technologies set a trajectory
for expansion which often trumped con-
cern for social aspects of wellness. While
becoming increasingly functional the
hospital was also perceived as austere
and disconnected from the community
at large.
These hospitals were typically centered
in urban areas and their expanding
programs resulted in larger, and more
complex buildings with footprints that
dominated their neighborhoods. Several
problems resulted in this rapid growth in-
cluding way nding, long commutes and
wait times, and disconnectedness to the
outside environment.
More recently, developments in the eld
of health care have brought promise for
more holistic models of care. Insurance
companies have increasingly noticed
the benet of preventative care and
have offered incentives for healthier
lifestyles. They have also been inuential
in reducing patient stays by pushing the
industry to develop better and faster
methods of recovery.
Recovery times have dropped due
to innovative technologies such as
arthroscopic surgeries and medical
implants. Likewise, technology has
improved communication between
providers through the use of electronic
medical records. Increasingly, the ability
to deliver care in alternative locations is
becoming a reality.
...wellness is as much a
collaborative aspiration
as it is a singular one. We
want to see our family
well, our community well,
and our city well.
Above: a man practices Tai Chi at dawn in
Tureen, China. Below: The Ospedale degli
Innocenti in Florence, Italy.
1
Gavitt, 230
Many healthcare systems are already
planning in this manner. Spectrum
Health System, serving West Michigan,
has been recognized by Thompson
Reuters as one of the top ten heath
systems in the United States
3
. They
have built a network of nine acute care
hospitals, a cancer center, heart cen-
ter, and 180 other service sites. Their
network includes 600 providers as well
as the Priority Health Plan with 625,000
members
4
. Spectrum Health has strate-
gically placed facilities within a master
plan in order to serve their clients with
high quality care.
The Central Hospital
As mentioned, a health care system is
made up of an array of different care
facilities. Each facility is strategically
located according to its unique func-
tion. At the center of the model is the
large acute care hospital. It is central
because of the need for specialized
providers and equipment as well as its
importance to reach a broad customer
base. These centers can become quite
Unbundling
While improvements to the hospital en-
vironment have been made, it remains
that for many the hospital is an intimi-
dating place. All to often, the hospital is
composed of a complex arrangement
of programs that can overwhelm the
patient. Way nding is often difcult
and access to the exterior environment
is limited. These, as well as many other
environmental factors can be stressful
and disorienting. For these reasons, it
is necessary to look at how patients
needs can be addressed through
thoughtful design.
The key to improving the quality and
positive experience of the hospital may
be in its unbundling. Unbundling involves
systematically removing programs that
are not essential to emergency care,
critical care, or other care requiring ad-
jacencies to equipment which requires
the infrastructure of a large hospital.
Technological improvement is con-
tinually revolutionizing the way hospitals
operate. This revolution is allowing
more procedures to be preformed at
outpatient facilities. Radiation therapy,
once considered hospital bound is nd-
ing its way into outpatient, freestanding,
cancer centers that provide a scaled
and comforting environment for an
otherwise unpleasant treatment.
Master Plan for Wellness
The relocation of medical services from
the urban hospital campus is encour-
aged by consumer based care plans
which have become for many the
preferred method of insurance
2
.
It used to be that health care payments
were made directly to hospital groups
therefore strengthening the connection
between a patient and a particular
hospital. Now, through advanced insur-
ance options, customers can choose
where they prefer care. This has revolu-
tionized how hospitals operate.
Hospitals are no longer a single building
or campus, but consist of an integrated
network of providers and services.
As such, there is signicant planning
involved in placing facilities. As the
healthcare system changes, a master
planning approach will help to develop
needed resources in critical areas.
large as in the case of teaching hospitals
and urban medical centers. Because of
their large scale there is an interest in un-
bundling services that can be placed
within better reach of the consumer.
The Community Clinic
Studies show that pulling services out of
large hospitals and placing them into
smaller community focused clinics often
increase customer satisfaction. In 1996,
the British J ournal of Rheumatology
published a comparison study between
a community clinic with a hospital out-
patient clinic in Rheumatology
5
. The
study showed that patients preferred
the community clinic for the following
reasons:
less travel time to local clinics
shorter wait list for initial appointments
longer consult times
more question were answered
Community clinics come in many dif-
ferent forms, but successful ones are
tailored to their surrounding neighbor-
hoods. Spectrum Health provides
services for many of its indigent patients
through the Baxter Wholistic Health
Clinic. Within a one mile radius, there
are 2,732 households that fall below the
poverty line and 80% of clients live within
the neighborhood
6
. The Baxter Clinic
achieves the World Health Organiza-
tions denition of health by addressing
the physical, mental, and social wellbe-
ing of its patients
7
. The center has many
programs that go beyond its medical
offerings and for this reason has been
well received by the community.
Long Term / Surgery / Spas
There are many other health related fa-
cilities that benet by being separated
from the central hospital. Not all are
addressed in this short article but they
range from long term care facilities,
surgery centers, and spas. In all of
the above, the patients experience is
critical to their wellbeing. In long term
care for example, patients should feel
at home and have some level of control
over their environment. Surgery centers
may benet from treating their patients
in a way similar to the hospitality industry
offering comfort and piece of mind.
Likewise spas can offer soothing envi-
Hospitals are no longer a
single building or campus,
but are an integrated
network of health services
and providers.
The Texas Medical Center is one of the larg-
est health centers in the world.
2
Kliment, 5
3
www.spectrumhealth.org
4
www.spectrumhealth.org
5
Lindley, 385
6
www.baxtercommunitycenter.org
7
www.who.int/hac/about/denitions/en
Spectrum Health System
ronments to limit stress and anxiety. All
of these benet from patient centered
environments.
The Continuum of Care
The continuum of care is dened in
may different ways according to the
type of services one is evaluating in the
health care sector. In general it refers
to the full range of medical services
that are available to patients in their
lifetime. Thus, it begins with prenatal
care, delivery, health promotion, and
disease prevention. Should one fall ill, it
may include diagnosis, treatment, and
rehabilitation. Eventually as patients
age they require nursing care, long term
care, and eventually palliative care
8
.
Each stage in the continuum of care
requires unique sensibilities in order to
appropriately care for the patient.
In each of the above mentioned
facilities different methods of care
are given for a specic set of circum-
stances. Some facilities are much more
geared towards the medical procedure
such as in an acute care or emergency
situation. These facilities require a high
pediatrics
family practice
internal medicine
episodic care
dental and/or eye care
traditional medicines
ayurvedic
physical therapy
mental health
psychology
Secondary care is an escalated level
of care which can be both ambulatory
and inpatient acute care
10
. Comfort
is equally important for the patient
however, specialization in staff and
technologies adds complexity to sec-
ondary care facilities. Secondary care
may include:
ambulatory surgery
radiology
urgent care
childbirthing
renal dialysis
Tertiary care is an even more special-
ized level of care and almost always
takes place within a large hospital with
a high demand for coordination of
services and technologies. Tertiary care
may include:
heart surgery
neurosurgery
burn units
It is important to point out that there are
several other levels of care and numer-
ous programs that have not been ad-
dressed in this short article which include
quaternary care, long term care, severe
mental health and more. It should also
be noted that all levels of care can op-
erate in one facility; however, a specic
building type may be more preferable
to one level of care than another.
Unbundling - Part II
Now that several levels of care have
been dened, it is easy to see what
types of facilities might best accom-
modate them from a patient oriented
perspective. If the large hospital com-
plex is the center of the health and
wellness master plan, then all the other
types of buildings will radiate out from
this point. A network of health facilities is
created according to markets, regions,
neighborhoods, and populations.
level of coordination with multiple
departments, technologies, specialists,
and services.
The community clinic on the other hand
benets from a more comfortable and
relaxing environment where one can
feel at home. While comfort as a goal
is desirable for all patients, the capa-
bilities are more achievable in such
a community environment. It makes
sense then to pair programs with build-
ing types that allow them to function
in an optimal way in terms of serving a
client population and their place in the
continuum of care.
Levels of Care
In order to determine what programs
can be unbundled from the central
hospital it is important to understand
levels of care. There are three primary
levels of care:
Primary care is the entry point into
the health services system
9
. As such,
it favors a high degree of comfort and
usually does not require a complex sys-
tem of technically supportive services.
Programs may include:
The complexity of the central hospital favors degrees of seperation between different users.
source: Hospital City by J onathan Hughes, 1997.
8
Barton, 5
9
Barton, 325
10
Barton, 334
The complexity of the urban hospital
may require the buildings footprint to
take over several city blocks. While
often necessary for its function, this
arrangement can be perceived as im-
posing and detrimental to community
focused care. The verticality of the ur-
ban hospital can be problematic from a
cost perspective as well as a functional
perspective and for this reason many
new hospitals are nding horizontal
integration to be a better alternative.
Of course, there are benets to having
a large urban hospital including the
aspect of concentration of knowledge
and research especially for teaching
institutions. Improvements can be
made to these centers to address the
needs of patients better; however the
remainder of this article will not address
these concerns.
Community health and wellness orient-
ed building types on the other hand are
nicely suited to the needs of especially
primary and some secondary care pro-
Repackaging Wellness
The South End Community Health
Center (SECHC) in Boston is an excel-
lent case study of a neighborhood
oriented care facility. The center is
located within a mixed use building at
1601 Washington Street. The surround-
ing community is dense and includes
housing for both high and low income
residents. Situated on the second and
third oors of the building, the center is
separated from the street activity but
has a generous entry hall with a promi-
nent entry canopy.
Once inside, the client ascends a
generous central stair into a double
height reception area which is bathed
by natural light via a two story glass en-
closure. The entry sequence allows for a
high degree of privacy while remaining
delightful. Once inside, the client feels
at home with warm colors and soft
materials.
A sense of community is generated
through the central reception area
because of its visibility to the waiting
grams. These centers are typically at
a much smaller scale and yet can still
provide for a broad range of health
services. Services can be grouped
together so that they benet certain
populations. For instance, neighbor-
hoods with a high percentage of multi
generational families may benet from
a center that groups together pediatric
clinics as well as physical therapy, and
dialysis treatment. These programs
may be very different, but all of them
can function successfully in this building
type.
Related facilities can be scattered
throughout the master plan. Retail
related to wellness will benet from
being in close proximity to the com-
munity center. Private practices and
alternative medicine groups may nd
it economical to lease space within or
close to the community center. Studios
for dance, yoga, or physical therapy
may locate nearby as well. All of these
benet from having street presence
and visibility within the community.
A master plan for health and wellness may include a large hospital at the city center with
surrounding community wellness centers. The community wellness center may be supple-
mented by related businesses such as pharmacies, health food stores, or exercise studios.
Each building type has a scale that corresponds with its function whether primary care,
secondary care, or a combination of different care levels.
tion of care, affordability of services,
and patient retention.
Yet, the idea of integrating clinical
practice with alternative medicines
within a community center continues to
be an attractive and holistic alternative
to other delivery methods and settings.
The SECHC is a successful model that
can be repeated and altered accord-
ing to specic needs of the neighbor-
hoods that such a center may serve.
Wellness services that are packaged
into a warm and receptive environment
have great potential to encourage
community interaction and growth.
Well informed designers have the po-
tential to show their clients how creating
such spaces can benet the health of
individuals as well as the community
as a whole. This is a worthy cause with
momentum and great potential.
rooms that surround it on both levels.
At the same time, privacy is afforded to
patients by wood and glass partitions
that enveloped waiting areas but do
not isolate.
In plan, the center features patient
exam rooms each with a window to
the street Clinical ofces are situated
directly across from the patient rooms
and therefore allow for integration
rather then separation of the two users.
There are community spaces including
conference rooms waiting areas, cafe-
teria, and terrace. Patient and provider
spaces are equal and complimentary.
Within the center there is a suite which
is currently occupied by Pathways for
Wellness a private practice of alterna-
tive medicine and acupuncture. Incor-
porating enterprise within a center is an
attractive venture for both clients and
providers especially with the potential
for a live/work situation within the build-
ing.
Speaking with a representative from the
organization it became clear that while
such a community center may sound
ideal, there are many challenges to
overcome in order to perfect this model
of care. Challenges include coordina-
community space
patient exam rooms
clinical ofces
conference spaces
utility / storage
Pathways
to Wellness
1601 Washington Street - Mixed Use Residential Homes and Condos
The SECHC is located in a mixed
use building with retail on the
street level and residential units
on the top three oors. The
entrance fronts Washington
Street. Underground parking
is shared with the residential
units behind the building and
features a secure alleyway.
There is a second story terrace
that is sheltered by the ends of
the building and looks out onto
the alleyway and neighboring
gardens. source: Arch. Record
opposite page: 1601 Washington Street is in the
South End neighborhood of Boston. Once inside,
after accending one ight of stairs, one enters the
double height clinic lobby and reception which is
surrounded by an upper mezzanine. Source: SECHC
bottom right: Clients exercise together at Baxter
Wholistic Health Clinic. Source: Baxter CC.
Third Floor Plan - SECHC
References:
Barton, Phoebe L. Understanding the U.S. Health Services
System. 2nd ed. Chicago: Health Administration Press, 2003.
Gallup, J oan W. Wellness Centers. New York: J ohn Wiley &
Sons, 1999.
Gavitt, Philip. Charity and State Building in Cinquecento
Florence: Vincenzio Borghini as Administrator of the Osped-
ale degli Innocenti. The J ournal of Modern History 69, no. 2
(1997): 230-270.
Helliwell, P S. Comparison of a Community Clinic with a
Hospital Out-patient Clinic in Rheumatology. British J ournal
of Rheumatology (1996): 385-388.
Hughes, J ohnathan. Hospital-City. Architectural History 40,
no. 1997 (1997): 266-288.
Kliment, Stephen A., ed. Building Type Basics for Heathcare
Facilities. 2nd ed. Hoboken, NJ : J ohn Wiley & Sons, 2008.
Valins, Martin S. Primary Heath Care Centers. Essex, England:
Longman Group, 1993.
Photo Credits:
www.archrecord.com
wwww.baxtercommunityclinic.org
www.sechc.org
www.spectrumhealth.org