Affordable Care Act has Exciting Impacts on Design

Design brings out the care in the Affordable Care Act.


Both providers and patients are still in the process of evaluating the impacts of the Patient Protection and Affordable Care Act (ACA). The implementation of its requirements—working toward a prevention- versus a disease-based approach and the creation of “wrap-around” services for Americans—has presented new challenges, as well as new opportunities in the design of healthcare settings.

The goal of creating a “continuum of care” is not a new idea for those with experience in the long-term care marketplace. Supportive services for residents living in their homes or moving through different levels of care elsewhere have supported our aging population for many years. However, gaps of coordination in the "continuity of care" (from acute to outpatient to long-term) exist among practitioners, health providers, family caregivers, and patients themselves.

The ACA is intended to fill some of these gaps by increasing the need for coordination and tying different performance aspects—such as patient and resident satisfaction, error reduction, and hospital-acquired infections—back to reimbursement. These considerations often occur in the context of evaluating reduction in operational costs: supporting organizational efficiencies, LEAN approaches to operations and design, and completing an upfront functional programming process prior to the completion of design and construction of a healthcare environment.

But what about viewing care in the context of the whole person—someone who may have dementia, other chronic conditions, sight and hearing issues, or simply be uncomfortable in an unfamiliar setting?

If care is required beyond rehabilitation and an individual cannot go home, additional post-acute or rehabilitation settings come into play either temporarily or more permanently (if they are leaving a hospital after a brief stay, for example, the acuity is often much higher than in the past). Assisted living, which is predominantly a private-pay industry, or skilled nursing, which is for those who cannot afford the former long-term rehabilitation settings are not always equipped to care for higher acuity residents, particularly those with dementia. Rehabilitation is reimbursed by Medicare at a higher rate than Medicaid for a shorter period of time and is intended to focus on the specific area required, such as orthopedics or cardiac. It is difficult to sustain operations for skilled nursing on Medicaid reimbursements, particularly with higher acuity needs.

putting the patient back in patient outcomes
The trend I see in response is larger scale nursing home providers that own and operate multiple homes in multiple states, creating a larger corporate model in order to sustain operations within tight economic constraints. Unfortunately, this does not always support the desired innovation of smaller scaled environments—such as small houses and household care models—which support less institutionalization and provide an environment that is geared toward living instead of clinical diagnosis.

But I also see nursing homes become part of Continuing Care Retirement Communities (CCRCs), which offer more opportunity to evaluate different resident-centered care models because they have other sources of revenue from independent living and assisted living settings that may be utilized for innovation. A number of mission-driven organizations are working toward establishing different, resident-centered models of care—but they too face difficulties, in that the existing institutional building stock is very large. We must challenge the design community to provide creative solutions that support these alternative care models.

The healing environments that assist outpatient and ambulatory care services need to provide support to the care population being served. The Patient-Centered Medical Home (PCMH) is the care model anticipated to provide “wrap-around” services to patients.

Operationally, decentralization can be efficient, but it requires upfront education and programming to shift the mindset from centralized services to provision of decentralized services. For new organizations, this is not as difficult. For a successful project to transform, it requires working in two directions—from the C-Suite (top-down) as well as from the hands-on caregiver level (bottom-up). Communication between different services is essential, even though it is difficult, and despite how many healthcare record systems are not compatible with one another.

A close relative of mine recently had to coordinate care for a potential cancer diagnosis. After speaking with her recently, I realized part of her anxiety and exhaustion results from having to wait for long stretches of time to learn useful information about diagnosis and treatment options. Fortunately she has a nurse navigator that helped her with the different steps, doctors, tests, and other specialists. Most people need someone to help with the personal journey and provide emotional support, regardless of age.

clear comparisons
At a recent presentation during the Healthcare Design Conference, a design and operational team presented clinic designs for rapid succession rollout. Unfortunately, the rapid succession was only focused on efficiency and provided no features for the users or caregivers. The layout included back-to-back examination and consultation rooms but didn’t consider that patients would include a range of ages. The waiting spaces were not geared towards patients needing multiple appointments or services in one day and had empty time between procedures. There were no foodservice capabilities or components, access to garden areas or views, or provisions for those using ambulatory devices or strollers. Staff space was completely internal and had no access to daylight in working areas or consultation rooms. It appeared that efficiency had replaced the human element that design is so adept at supporting.

In contrast, a creative approach by Iora Health evaluates the environment from an efficiency and output perspective, but with the caveat that each person who enters the clinic is met by a health coach who becomes their connector to services. A small foodservice component is included. Seating in the entry area accommodates patients being accompanied by a friend or family member. An educational area is provided. Collaborative space for staff is centralized and bull-pen style, but it also provides private spaces and “phone booths” for quiet conversation. Overall, a sense of community is developed within the setting. It reminded me of the new Starbucks office model with private areas, shared space that can be used by different disciplines.

With these advancements, designers are encouraged to hold focus groups and discuss the care population at length. This process was utilized by Iora Health in developing their Phoenix and Seattle locations. It allowed them to evaluate each new setting and test different configurations for staff and patient needs. Future discussions will lead to adjustments in design based on region, need, outcome, efficiency, and—perhaps most importantly—the human factor.

Jane Rohde, AIA, FIIDA, ASID, ACHA, AAHID, LEED AP, is the founding principal of JSR Associates, Inc., located in Ellicott City, Md. She champions a global cultural shift toward de-institutionalizing senior living and healthcare facilities through person-centered principles, research and advocacy, and design of the built environment. Clientele includes non-profit and for-profit developers, government agencies, senior living and health care providers, and design firms. Rohde speaks internationally on senior living, aging, healthcare, evidence-based design, and sustainability. For more information or comments, please contact her at