Community-Based Healthcare Design in Non-Urban Locations
Author
Margaret Wilson & Hayley Purdy
As architects, especially healthcare architects, we consistently hear of similar obstacles and challenges and are asked to address them through design. For non-urban communities, we often encounter numerous hurdles specific to their location—lack of readily available care, a tendency toward older populations and lower health outcomes, patients having to travel long distances, a limited number of providers in the region, staffing shortages, with several of these barriers discussed extensively in “Differences in Rural and Urban Health Information Access and Use” and the CDC’s “About Rural Health”. From this experience, we have identified opportunities for architecture to contribute meaningful solutions to these pervasive issues, supporting a holistic approach to community-based healthcare design.
In this piece, we examine architecture’s role in bettering community health and wellness. We apply the lens of three different user groups to three SEA-designed non-urban healthcare facilities, exploring how thoughtful design can support community health centers proactively and efficiently deliver care. From these case studies, we can draw best practices applicable to non-urban healthcare projects moving forward, beneficial to our collective societal health.
The three projects we will be focusing on are Nehalem Bay Health Center and Pharmacy, Virginia Garcia Memorial Health Center Newberg Wellness Center, and One Community Health Hood River, detailed below:
Nehalem Bay Health Center and Pharmacy
Location: Wheeler, OR
Primary demographic served: Geriatric
The Nehalem Bay Health Center and Pharmacy is a community-based healthcare clinic serving the north Oregon coast. We understood from the client the importance of this clinic in increasing access to health and wellness services and providing additional services as a community asset. The health center is currently under construction.
Virginia Garcia Memorial Health Center Newberg Wellness Center
Location: Newberg, OR
Primary demographic served: Latinx, farmworkers, under or non-insured
Virginia Garcia Memorial Health Center’s Newberg Wellness Center is a renovation and addition to an existing building that expands the health, dental, and wellness services they’re able to deliver. As a Federally Qualified Health Center, the Newberg Wellness Clinic is community-based and provides primary care and support services to underserved populations. The wellness center is currently under construction.
One Community Health Hood River
Location: Hood River, OR
Primary demographic served: Historically, farmworkers, but has expanded to serve entire Hood River County community
One Community Health Hood River is an integrated health facility focusing on whole-person team-based care. The facility provides medical, dental, primary, and behavioral health care, and now with the new building, has the much-needed functional space to administer each service. One Community Health Hood River opened in 2020.
Using these three projects, all non-urban community health centers in Oregon, we will demonstrate design responses for three user groups—Patient, Staff, and Community. From this practice, we identify similarities, differences, and opportunities for healthcare design to make an impact.
User Group—Patient
Delivering quality healthcare to patients is the primary intent for developing this resource. Each architectural response is patient-centric, applying the principles of trauma-informed design to create a comfortable, inclusive environment. Below we examine key components through the lens of the patient user group.
Medical and Mental Health - All three projects have medical services as the primary use of the building.
All three projects have procedure rooms. Based on reimbursement, procedure rooms are one of the more profitable spaces in community health centers and they typically help offset other programs that are traditionally unprofitable. Procedure rooms are critical for the overall operation of the facility and a priority in the programming.
For Nehalem Bay, it was critical that an onsite x-ray was programmed in the building. Within the Nehalem Bay Valley, there is a lack of imaging services. The closest imaging services are offered more than 25 miles away. Prioritizing X-rays in the new facility ensured this community would have access to a vital diagnostic tool without the burden of extensive travel.
For the Newberg Wellness Center, it was critical that specific spaces were designed to be mental health-focused. Often in rural healthcare settings, rooms are used for multiple purposes, and typically, this is a great solution for efficiency. In the case of exam rooms being used for mental health appointments, this is not ideal.
When considering how a room is designed, the interaction between the provider and the patient is significantly different in exam rooms versus mental health spaces. In exam rooms, the patient often sits or lies on an exam table while the provider is standing. This allows for eye-to-eye contact and provider ergonomics. In a mental health setting, a homelike, deinstitutionalized environment is more conducive to discussion while reducing stress and the potential for escalation, discussed in detail in “Design for Behavioral and Mental Health: More Than Just Safety”. In this case, both the provider and patient are sitting and still have eye-to-eye contact. Having space designed specifically to deliver mental health care is critical to improving health outcomes.
A procedure room at One Community Health Hood River
Pharmacy - All three projects have pharmacies onsite.
Prior to the renovation, the Newberg Wellness Center identified challenges with patients filling prescriptions, either delaying or never starting the prescribed medication. By locating a pharmacy onsite—and programming it with adjacency and convenience in mind—they can quickly fill the prescription during an appointment before the patient leaves, increasing medication participation, therefore improving health outcomes.
For Nehalem Bay, it was critical to have a pharmacy onsite to ensure patients, especially the elderly, were filling and taking their prescriptions. With the nearest pharmacies more than 30 minutes away in Seaside and Tillamook, it was clear travel would be a burden and hindrance to patients receiving their necessary medications. This is a challenge along the entire Oregon Coast and has a significant impact on community members and their long-term health—ensuring we provided an adequately sized pharmacy to meet community demand was crucial to the Health District's mission.
For Nehalem Bay, having access to a 24-hour pharmacy was critical because patients often expressed frustrations about the pharmacy's operating hours. In the design, particular attention was given to creating a vestibule and dispensing system that maintained medication security and still promoted access.
In non-urban settings, staffing pharmacies is difficult. Pharmacies require at least one pharmacist to be onsite during all open hours, and with recruiting challenges in non-urban areas, this can be a barrier to care delivery. We discuss methods for design to respond to staffing challenges in the User Group – Staff section later in this piece.
Dental – All three projects have dental incorporated into the design.
For Newberg Wellness Center, dental was fully integrated into the whole healthcare approach to care delivery. Although the dental operatories are segregated in the floor plan because of existing site constraints, dental patient check-in and staff are integrated with medical, signaling the Center’s holistic approach.
The Newberg Wellness Center operates a mobile dental care bus, allowing staff to go out to meet patients where they are. As part of the programming, our design incorporated home desks for the mobile staff while they aren’t on the road, facilitating a flexible, connected staff environment.
One Community Health Hood River did not previously offer dental services, but in their new facility and as part of their holistic health model, they understood the importance. Anticipating future utilization and tremendous community need, we incorporated 17 dental operatories. As they hire dental providers, they are slowly opening operatories as a phased approach to address the growing need for dental care.
At Nehalem Bay, a tremendous community need was also identified, but they understood that hiring staff to support the new service line was going to be challenging. To balance current resources with anticipated future use, we incorporated three built and furnished dental operatories and left two operatories to be built-out as needed or as funds became available.
Multi-Purpose Indoor and Outdoor Spaces - Multi-purpose rooms distinguish community health centers from other healthcare facility types. These types of flexible spaces allow them to provide quality and tailored programming specific to their community and intended to improve health outcomes.
The Newberg Wellness Center includes both interior and exterior multi-purpose space designed to flex to meet the ever-changing programs for wellness. For the interior space, SEA designed a space that can easily transform between a teaching kitchen, exercise classes, vaccine clinic, all-staff meetings, small conference rooms, community presentations, and more, accomplished through durable finishes that could support all the desired potential uses, a partition to separate spaces into smaller spaces, attention to acoustical properties of the room to allow for loud music to be played without disrupting adjacent spaces and storage for flexing uses.
Newberg Wellness Center’s exterior incorporates spaces that can be used as a community garden, children’s play area for decompression before or after visits, vaccine clinic, food pantry pick-up, and more.
One Community Health Hood River incorporates an indoor multi-purpose space. The space was envisioned as having numerous community uses and could accommodate the entire OCH staff from all their clinics for quarterly meetings. It also proved to be vital at the beginning of the COVID-19 pandemic when it opened. Because of the flexible design, the space could transform into an efficient vaccine response center. The facility was able to support efficient vaccine distribution to a significant number of people in the community, contributing to Hood River County achieving the highest vaccination rate in Oregon at the beginning of 2022.
Transport – Patient transportation options and preferences varied widely between our three projects. During engagement, our team pursued information that would help us target design responses with the intent to remove one of the most significant barriers to accessing care.
During preliminary design, the design team discovered a unique aspect of the patient demographic at the Newberg Wellness Center—a large number of patients’ primary mode of transportation is walking or biking. In response, we incorporated a public bike repair station as a community amenity and increased the amount of bike parking.
At Nehalem Bay, a transport van is available to pick patients up. We designed the parking lot to accommodate a larger turn radius for this vehicle to ensure smooth pick-up and drop-off.
User Group—Staff
Designing thoughtful spaces for support, team building, and respite increases staff recruitment and retainage. Architecture can create opportunities for connection and collaborative delivery of healthcare, leading to a positive work environment, and designers can identify places to elevate and celebrate the work performed within and how meaningful it is to community health.
Transport
Like patients, several staff surveyed at the Newberg Wellness Clinic also used biking as their primary mode of transportation. As well as access to the larger number of bike parking spaces and the bike repair station, the building also incorporated a staff shower, ensuring comfort during the workday after biking in.
Staff Spaces
Each project extensively discussed an open office bullpen or team room versus individual staff offices. We found that because space is a premium for community health facilities and increasing staff communication was a priority, all projects chose to pursue open office bullpens/team rooms.
For Newberg Wellness Center, we fully integrated all care staff—medical and dental—to provide increased communication between the disciplines in alignment with their holistic care delivery. We also programmed an increased number of desks for students, supporting the education of the next generation of providers, a home base for staff traditionally on the road (like their mobile clinic workers), and staff that rotates to each clinic.
At Nehalem Bay, we met with the outreach coordinators, who mostly work in the community, to understand how frequently they were in the health center, what their spatial and programmatic needs were, what their desired physical proximity to patients and staff was, and any other unique requirements they have to facilitate care delivery while in the health center.
Staff team room at One Community Health Hood River.
Staff Culture – Essential for staff recruitment and retention, each building is designed with specialized areas for staff culture building.
Each project designs areas for staff respite, including a quality staff break room that is beautiful and calming. The design offers multiple types of seating and lighting as well as areas that are open for socialization and more enclosed for privacy. Staff can decide where they want to sit depending on what they need for respite.
Newberg Wellness Center has an indoor and outdoor staff area. These areas are private from the patient zones allowing for staff to recharge. In addition to the indoor and outdoor spaces, staff desired a walking path. During engagement, staff shared that they encourage exercise for patients, but they don’t have the opportunity to exercise on their lunch break. They noted that they didn’t feel comfortable walking in the neighborhood because there weren’t sidewalks on adjacent properties, so we designed a walking path onsite. Along the path are simple exercise apparatuses for some quick step-ups or pull-ups.
Newberg Wellness Center has increased areas for staff training and school integration, including a mock exam and medical lab for learning exercises. One of Virginia Garcia’s primary goals is to always be growing the workforce from within and these spaces support that goal.
The landscape design at Newberg Wellness Center promotes pockets of respite for both visitors and staff. It complements the architecture by creating moments that give a nod to patterns and textures used in the architectural design while also supporting the community-centered approach to make usable, comfortable, and engaging outdoor spaces. Rendering courtesy of PLACE.
User Group—Community
Gathering Spaces – Indoor and outdoor multi-purpose spaces not only provide areas for patients and staff, but they can also provide spaces for the larger community.
In Nehalem Bay, they wanted the facility to be seen as a community landmark. The new clinic’s site rests on top of a hillside overlooking the Nehalem River and is visible from Highway 101, the main thoroughfare through town. The design demonstrates quality and responds to context, situating it within Wheeler and signaling that this is a place that belongs to the entire community.
In Nehalem Bay, the building was adjacent to City Hall. The City Hall didn’t have a space large enough to accommodate a large public meeting, so the multi-purpose spaces were designed to allow for that use.
At the Newberg Wellness Clinic, all the multi-purpose spaces allow for use by the community, particularly off-hours and weekends.
The Nehalem Bay design concept is informed by the site’s natural context, pulling inspiration from the forests and marshlands that characterize Wheeler’s environmental surroundings. Ensuring the building felt “of its place” was important to SEA’s designers and the Wheeler community.
Air Quality – For each project, air quality was a discussion point during design. As in all healthcare design, keeping contagions contained was important, and with design and implementation during and following COVID-19 timelines, each project further elevated air quality as a primary concern.
For Newberg Wellness Center, whose design was underway in the aftermath of COVID-19 and extensive wildfires in the region, air quality was noted as one of the most important design aspects. We implemented increased MERV filtration, UV ionization, and low air returns in key areas. Operable windows were also incorporated for natural ventilation.
Also at Newberg Wellness Center, two exam rooms with a separate entrance allowed for direct access to the clinic for patients that were suspected of having a highly contagious disease. In non-urban locations with constrained capacity, mitigating spread is vital, and design solutions support that mitigation.
At One Community Health Hood River, with the building under construction during the start of a global pandemic, these features (MERV filtration, UV ionization, low air returns, and natural ventilation) were enhanced and improved during construction.
Resiliency – Resiliency is a key concern in healthcare design because in the case of an emergency, the operation of the facility is vital. In non-urban locations, the importance of remaining operational is perhaps more important, because it may be the only place in the region to access care. As healthcare architects, we bring to our clients right-sized solutions for resiliency that balance budget, project priorities, and site-specific considerations.
For Newberg Wellness Clinic, it was important to provide an all-electric building in conjunction with an 80.6 KW solar array. With an Energy Trust of Oregon ($28k incentive) and PGE EDF ($190k grant), the solar array will pay for itself in 4 years and continue providing sustainable energy well beyond.
For the Nehalem Bay project, the electrical grid system has frequent and lengthy outages. The design planned for a diesel generator onsite that would allow for the building to remain in operation during the frequent outages and ensure that critical medications and supplies were protected.
Architects are in a unique position to contribute to places and initiatives of all types. Our design work can make accessing care and services easier, build and strengthen community connections, and promote discovery and joy in daily life. In healthcare architecture, we see an opportunity for our experience to help make meaningful improvements to community health outcomes, and in non-urban locations and otherwise, we are eager to continue our work doing so.
About the Authors
Margaret Wilson is a Principal at Scott Edwards Architecture and has over 23 years of experience in the architectural profession. She cares deeply about healthcare design, in particular community design for wellness, and is passionate about using architecture to improve how healthcare is accessed and experienced. Margaret finds that intersectional projects combining healthcare with residential, retail, and community spaces tend to stick with her, and she enjoys using this multi-typology approach to respond to layered needs. She brings to her work a strong design and technical skillset and advocates for a collaborative work environment that centers the project vision and lifts up new ideas.
Hayley Purdy is a Principal at Scott Edwards Architecture and leads a team that pursues community-focused work. Her passion and experience, along with her ability to push design forward, has given her a versatile skillset as a designer and leader. Hayley promotes resiliency and equity in architecture, applying this lens to solutions to create stronger responses. Her work often includes significant community involvement and creating unique, integrated spaces that are highly contextualized. She is passionate about design’s role in bettering people’s lives, and her past work in community-based healthcare, affordable housing, libraries, adaptive reuse, and historic preservation has proven particularly rewarding.
