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  • 03.27.17

How The Affordable Care Act Is Transforming Health Care Design

The law’s focus on integrative medicine relies on people seeking care before they’re sick–and design may play a critical role.

Meridian Health, a new clinic in northwest Seattle, celebrated its grand opening early last year. The two-story building is clad in rust-toned weathering steel and concrete masonry units of different dimensions, jigsawed together so they look like natural stone. Wood benches are stationed underneath the deep eaves and, from there, visitors to the clinic have an idyllic view of a pond, lush aquatic plants, and trees including a fluffy willow. The building looks like it’s nestled into nature, and the theme continues inside. The admissions desk is stationed beneath a double-height atrium and a skylight. The wall behind the desk is wrapped in strips of reclaimed wood, and there’s a statuesque, rough-hewn stone slab there, too.

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Meridian Health is beautiful, not institutional. And there’s another attribute that makes it special: Medical, dental, mental health, public health, and chemical dependency services are all found in this one clinic, instead of being scattered at different sites throughout the city—a thoughtful approach that centralizes health care.

But here’s the kicker: This thoughtful building and its comprehensive approach to care was purpose-designed for low-income and underserved communities. And without the Affordable Care Act, Meridian Health probably wouldn’t exist. “That’s a direct result of policy,” says Richard F. Dallam, managing partner and leader of the international health care practice at the architecture firm NBBJ.

President Obama signed the Affordable Care Act seven years ago last week. Since then, providers have slowly changed their approach in a response to the law’s provisions, which emphasize a holistic approach to medicine, preventative measures, and bringing services to more people. It’s unclear if the ACA will endure, despite the high-profile failure of the Trump administration’s first major legislative action to repeal and replace the law. But some of its longer-term benefits are beginning to come into focus, as the first crop of hospitals and clinics to be built since the ACA’s approval are now coming on line. These projects show how the embattled health care policy is influencing health care architecture.

Meridian Center for Health. [Photo: courtesy of NBBJ]

Holistic Care Calls For Holistic Architecture

The ACA’s purpose was to make health care available to everyone in the United States, regardless of income level. While accessibility was an important part of the plan (it’s estimated that 20 million people gained health care coverage as a result of the law), one of its biggest mandates was a shift to a preventative approach to medicine, rather than treating the consequences of falling ill, while a third shift involved focusing on integrative care.

It’s easy to see the outlines of the policy in Meridian Health, which was formed after multiple organizations came together. That included Neighborcare Health, the largest provider of primary medical and dental care to low-income populations in Seattle; the Seattle-King County department of public health; and Valley Cities Mental Health Treatment, a community-based behavioral care organization. The idea behind the center illustrates how the ACA aimed to encourage preventative, integrative care: Providers at each organization collaborate and think about a person’s health holistically. For example, they might look at behavioral difficulties that manifest as physical symptoms. Patients can see multiple providers in one location instead of having to travel to scattered facilities.

“If you have a 16-year-old boy who is obese and he comes in for a visit, in a typical system he gets treated and he goes home and he’s in the same situation,” Dallam says of doctor-centric models of care delivery. Meridian uses a care-team approach, meaning that multiple providers might see a patient in a single visit. “The problem is we live in social groups, and those groups impact health and well-being. A care team gets to the root cause.”

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The clinic is also a community center. Its location, in the neighborhood where the majority of the people it serves live, means that there isn’t a travel burden associated with visiting. The building’s public spaces are open to community groups in the evening. Resources like job training and résumé writing are expected to be offered.

“The ACA drove the notion of collaboration as a way to become more effective and efficient,” Dallam says. “If [health care is] protecting lives, we have to look at a whole life, not just a condition.”

While Meridian Health represents a planned, strategic approach to clinics based on the anticipated impact of the ACA, the law has also yielded unexpected outcomes that hospitals are grappling with spatially.

Nimble Buildings For A System In Flux

By focusing on preventative care, the ACA was designed to reduce emergency room visits, which are expensive and drive up overall cost of health insurance. However, some hospitals have actually seen an increase in ER visits. It took a few years for the ACA to go into full effect, particularly the way reimbursements for physicians’ expenses were financed—and when the payment structure changed around 2014, ERs saw a surge of patients.

“[Providers] predicted the exact opposite,” Dallam says. “We designed legislation, but we didn’t design a system, for primary care . . . One of the biggest issues [in health care] is it’s probably going to take a decade to build a primary-care network focused on covering lives and moving from an intervention to a health focus.”

Meridian Center for Health. [Photo: courtesy of NBBJ]
 Now, some of NBBJ’s health care clients are at capacity and need more beds to accommodate patients. The design challenge is that, in the short term, hospitals need to accommodate more patients in emergency rooms and need more beds for increased admissions due to the influx of millions of new people into the health care system spurred by the ACA. But if the law works as planned, hospitals won’t need as much space in the long run.

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Whatever is designed and built now needs to be flexible enough to handle change in the future.

“If you’re healthy, you don’t need nearly as much intervention later in life,” Dallam says. “If you take care of yourself, and have a system that takes care of you, you’ll have fewer health problems. Clients are building things they won’t need. In the future, you won’t need as many beds, you won’t need as big of an ER. But we’re having to build them in the interim. One of the key issues is how you can convert what you’re building now to other uses that are meaningful in the future.”

NBBJ typically factors in a 50- to 100-year shelf life for medical buildings, and Dallam figures that there are at least 10 major change cycles that a typical structure must accommodate. Each design must be flexible to accommodate unforeseen needs. For instance, now the firm typically relegates a building’s fixed infrastructure—like main plumbing and electrical systems—to its edges, so the internal walls can be demolished and rebuilt as needed.

While it’s a challenge for architects, it’s not a completely new one. Care delivery models are influenced by policy as well as best practices in a profession. Dallam estimates that the models change every three to five years. Meanwhile, providers are also changing the technology in their clinics and hospitals, which is on an 18-month cycle. “There is always an arms race for who has the best tech,” he says. “That means your facility has to be easily modifiable so your building is adaptable for rapid technological change.”

Designing Spaces That “Celebrate The Circle Of Life”

All this change, while necessary for advancements in care, can often be confusing for patients who repeatedly visit. Wayfinding, as a result, has become a much larger focus of NBBJ’s design process. “What you don’t want to change are the ‘front door,’ the public spaces, circulation, and waiting areas,” Dallam says. “To a large extent, we like them to remain permanent because they’re the orienting and socializing spaces that help us through our most difficult times and more joyous times.”

When Dalham’s father died, he and his family couldn’t find their way out of the hospital from the ICU. However, in the process of getting lost, they came across the maternity ward and its waiting area, where they saw families rejoicing over a new baby. “Hospitals have to celebrate the circle of life in public spaces,” he says. “They have to be humane and permanent. The finishes can change with season and style, but the access to daylight, that has to be permanent. Most hospitals aren’t designed like that. They’re optimized for the first use, but they have to be optimized for the tenth use.”

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NBBJ’s renovation of Swedish Edmonds—an ambulatory care center in Edmonds, Washington—embodies how a hospital’s structure can incorporate wayfinding. The firm expanded the hospital’s ER and built a new entrance. A large canopy, like a front porch, is an eye-catching, intuitive beacon that draws attention to the front door. The building’s facade transitions from opaque to glass, which could be read as a metaphor for openness. Additionally, the landscape design—like the paths from the parking lot to the building—direct people to the door. Inside, NBBJ used landmarks as wayfinding mechanisms, adding artworks and sculptures so visitors don’t have to rely on signs alone.

“A lot of people confuse wayfinding with signage,” Dallam says. “Health care deals with the most diverse population of any industry. You have different languages and a higher level of illiteracy, so if I can’t read the sign, the sign is useless. We started using artwork and things that regionally reference as landmarkers to make it easier to navigate.” The interiors are filled with natural light and wood finishes, a nod to the history of logging in the area. The firm was able to source some decommissioned log booms—barriers that are placed in rivers to captured felled trees from the timber industry—for the interior.

While thoughtful design touches serve functional purposes—from regional details that serve as wayfinding to space planning that allows doctors to deliver care in a integrative way—the overall aesthetic is important, too. Establishing trust in the system was an important prerogative in particular for Meridian Health, since low-income and homeless populations are often wary of hospitals. Meridian’s warm, light-filled atrium, its materiality, and its park-like surroundings were designed to do just that.

But regardless of the specific demographics of a patient group, for the ACA’s preventative approach to work, people of all walks of life have to routinely seek out care. Now, architecture is emerging as a critical tool in convincing them to do so.

“You want the environment to encourage people to come,” Dallam says. “It has to be safe, and it has to create a social connection where people feel like they have a save place to come and they’ll be cared for.”

About the author

Diana Budds is a New York–based writer covering design and the built environment.

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