In the 1990s, Frank Pitts, architect and founder of Architecture+ (Troy, N.Y.), says his firm engaged a consultant to assess the mental health design market. Specifically, Pitts wanted to know if the sector was a viable focus of work for a small firm like his. The expert concluded it wasn’t—an answer that Pitts says was both right and wrong at the time.
“She was right that there was no market in the larger scheme, but there was a niche market,” he says. And with so few firms specializing in mental health design, his firm found a path for growth. “You can’t say that today,” Pitts says. “It’s astonishing to see the volume of work that’s happening right now and the number of our colleagues who are paying attention. It’s not a niche practice anymore; everybody is doing it.”
The uptick in activity is being driven by a variety of factors, according to architecture firms and industry consultants across the country. For starters, Pitts, who has now spent much of his 40-plus-year career as an advocate, educator, and designer for psychiatric facility design, says there was pent-up need and demand for services that weren’t addressed for decades. Then, more recently, new or expanded legislation and standards pushed a trend toward greater investment in treatment, including the Affordable Care Act, which broadened mental health and substance use disorder coverage and required parity with medical and surgical benefits.
As more design professionals are being personally impacted by mental health issues within their families or communities, Pitts says he’s seeing some make commitments to take on mental health work at their firms in an effort to help make a difference.
Regulatory agencies are also playing a role, with the Joint Commission and Centers for Medicare & Medicaid Services recently addressing suicide prevention and ligature risk in facilities, while the Facility Guidelines Institute has updated codes and safety requirements in existing behavioral health facilities, igniting an increase in renovation and retrofit projects, says Kimberly McMurray, principal of Behavioral Health Facility Consulting LLC (Tuscaloosa, Ala.).
New and expanding avenues of funding, including rural health and mental health block grants from the U.S. Department of Health and Human Services, are also driving more support to this growing market, she says. “Up until the last few years, behavioral health projects have been minor renovations,” McMurray says. “Only since behavioral health came out of the shadows and into the light and funding started to become available could organizations do significant renovation to projects and in some cases build a new unit.”
Surveying the landscape
All these factors are bringing a breadth of new facilities to market, with recent projects ranging from inpatient hospitals to crisis units to pediatric specialty centers. Some of these facilities are designed to reflect new patient-centered approaches to mental health services while others aim to help divert behavioral health patients from emergency departments. Tony Breitlow, senior project manager and associate at Eppstein Uhen Architects (EUA; Milwaukee), says a lot of work on the inpatient side is focused on updating facilities with a focus on aesthetics, while on the outpatient side he’s seeing more new construction as the need for care grows. “There’s an opportunity to get rid of the white box and sterility of the past and make it more comforting and warmer,” he says.
Additionally, as there’s been a reduction in stigma around the topic of mental health and growing recognition of the importance of early diagnosis and treatment, facilities are no longer isolated in rural or suburban settings but given more prominent locations. “You certainly see a more general discussion in the public about mental health, and it’s not as much in the shadows anymore,” Breitlow says. “We’re also seeing that in built form, too. Behavioral health departments and treatment areas don’t have to be buried in the basement or down the hallway behind an ominous door.”
The state of Indiana recently completed its first mental hospital in more than 50 years, opening the NeuroDiagnostic Institute and Advanced Treatment Center (NDI) in Indianapolis in March 2019. The 159-bed facility, designed by BSA LifeStructures, is located on a tight footprint on an existing medical campus, driving the building’s vertical design and a new connector to the existing hospital. Other recent examples include Kaiser Permanente Northern California’s renovation of an existing medical/surgical unit at the Kaiser Fremont Medical Center in Fremont, Calif., into its first inpatient medical/psychiatric unit.
While most early behavioral health projects were focused on adult populations, Scott Holmes, principal at BWBR (St. Paul, Minn.), says within the last five to seven years, he’s seen an increase in both child and adolescent facility projects that are geared to different age groups. “Traditionally, anything you saw related to pediatrics was all the same, but you really need to break down that population because there are big differences physically, mentally, and emotionally between a 6-year-old and a 17-year-old,” he says.
For example, BWBR renovated and expanded UnityPoint Health-Meriter Child & Adolescent Psychiatry Program in Madison, Wis., which provides both inpatient and outpatient community-based psychiatric services for children ages 6-18, to include a 10-bed children’s unit with common support spaces and a 12-bed adolescent unit with another eight beds converted to serve tweens exclusively.
With mental illness and substance use disorders involved in one out of every eight emergency department visits by a U.S. adult in 2007, according to a Statistical Brief by the Agency for Healthcare Research and Quality, there’s growing discussion about the continuum of care for behavioral health patients and increased recognition that there needs to be crisis resources for mental health patients in communities, as well.
McMurray acknowledges that strides have been made, with some EDs having dedicated psychiatrists on staff and adding observation units with ligature-resistant design features. “But we’re not anywhere close to where we need to be across the country with treating crisis care and figuring out what that looks like outside the hospital,” she says.
On the clinical side, Pitts says that means figuring out how to operationalize models around early detection and treatment that minimize the number of people who end up in an ED.
“There are people all over the country working on how to solve this problem of the overstretched emergency department,” with models looking at community intervention combined with crisis centers as part of an ED, co-located with an ED, or as a separate facility, he says. (To read more about behavioral health crisis stabilization units, read “Decompression Space In Behavioral Health Design” here.)
While in the past, sterile facility designs reinforced a stigma associated with mental health treatment, today’s light-filled, open, and welcoming environments are sending a different message, says Justin Brooks, principal at ZGF (Portland, Ore.). “It tells patients that they’re welcome here and that this is just part of normal healthcare treatment. And it also makes patients feel more inclined to come back and finish their treatment, which leads to better outcomes,” he says.
As such, conversations with clients are moving beyond the importance of safety and ligature-resistant devices to how patients interact within the space and what design strategies can help reduce agitation and create a positive first impression. “What’s really evolved over time is that safety elements aren’t as apparent as they used to be, but they’re built into the way we lay things out from a planning standpoint,” says Tim Spence, president of BSA LifeStructures (Raleigh, N.C.).
To help set patients at ease, strategies to “humanize the space” that are employed in other healthcare environments, such as providing access to nature and natural light, are also being embraced in mental health settings. Aesthetic approaches have evolved, as well, with more colors and natural textures being incorporated in materials and products appropriate for behavioral health environments.
For example, the project team on NDI focused on creating an open-concept design with laminated safety glass walls and partitions that provide spatial separations without impeding the flow of light throughout the space, while also introducing calming colors inspired by nature. “It’s right on par with a lot of modern healing environments,” says Derek Selke, architect and principal-in-charge at BSA LifeStructures (Indianapolis).
Demand for private inpatient rooms with en suite bathrooms has also grown,
mirroring another trend seen in other healthcare environments. Additionally, Holmes says clients are recognizing the importance of giving patients a sense of control within patient bedrooms or quiet rooms where they can go to calm down or be alone.
“We take away their shoes, their belt, cell phone, anything that can be a potential risk—sometimes against their will,” Holmes says. “So what can we do to give back some sense of control?” Among the strategies he’s seeing employed is incorporating color-changing lights or music controls in patient rooms or quiet rooms.
Another change impacting behavioral health design is the growth in community spaces, including day rooms, patient lounges, and activity rooms, which can accommodate different therapies or group activities. And while these settings are found in other healthcare facilities, on a behavioral health inpatient project, teams must also consider such factors as spatial and social density. For example, cramped spaces and a higher number of patients within an area can contribute to increased stress among patients and lead to more aggression and violence.
“As a result, we typically space furniture farther apart and talk about smaller clusters of seating within an area and/or providing a number of smaller spaces designed for one to two patients,” Holmes notes.
Strategies addressing staff work environments and safety are also evolving. For example, some facilities are choosing to reconfigure team stations to break down that barrier between staff and patients to encourage more interaction and support patient-centered care strategies. (For more on these approaches, see “Rethinking Team Stations In Behavorial Health” here.)
McMurray says she also encourages facilities to consider the use of onstage/offstage layouts, which can be used to bring ancillary, pharmacy, and dietary services to a unit safely without interacting with patients, as well as provide staff with a place to step off the unit for a break or to collect themselves when necessary. “It’s about staff safety as well as satisfaction and retention,” she says.
Getting out ahead
Looking to the future, many design professionals say issues including the current opioid crisis, post-traumatic stress disorder, and the rise in childhood suicide rates will keep mental health services in demand, while recognizing the challenges the industry faces with a shortage of providers, inpatient beds, and ongoing issues related to funding and parity with reimbursements. Holmes says he acknowledges that organizations that offer services have been “very innovative in how they stretch their dollars,” but says more innovation is needed, particularly in outpatient programs and facilities, crisis centers, and transitional residential facilities.
Many experts point to the lessons in telehealth gleaned from the COVID-19 pandemic as a possible solution for improving care access, including to rural and underserved areas. Selke also sees the need for a more comprehensive system that focuses on delivering care earlier, especially to children and adolescents. “I think that getting out ahead of this and providing better services for children is an important long-term outlook,” he says.
Pitts says he’d like to see more conversations about the models of care that proceed hospitalization, including early diagnosis and treatment in community settings, to improve outcomes and reduce need for longer-term hospitalization. “If that does happen, then 20 years out it will create a really significant change [in the system],” he says. “This is a disease that’s so debilitating and there are so many people suffering from it, and I think we’re starting to understand what it really costs us not to treat it or not treat it well.”
Anne DiNardo is executive editor of Healthcare Design. She can be reached at firstname.lastname@example.org.
For more information and photos on recent behavioral health facilities, including some of the projects mentioned in this article, visit HCDmagazine.com/projects/behavioral-health.