Fire Station Health Centers: Designing Health Care Access

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Concept design for co-located health portal and fire station, by RossDrulisCusenbery and
Muller & Caulfield Architects

Implementation of the Affordable Care Act will topple one of the great health care access divides by providing insurance to millions of uninsured Americans. But it’s important to remember that insurance is only one piece of the health care access puzzle. There are also a number of cultural and geographic barriers, which the traditional model for the design and distribution of health care facilities does not address.

Currently, sixty-five million Americans live in officially designated primary care shortage areas. Due to the long wait times to see a primary care physician, these individuals are more likely to seek care from Emergency Departments, where they will generally receive a reactive and episodic form of care that is ill-suited to address the roots of health issues. Not surprisingly, this population tends to have the higher rate of chronic health issues, disease, and death. Compounding insufficient supply and poor distribution of primary care are cultural barriers in terms of both the care itself and the design of medical environments. These barriers can take the form of communication challenges between patients and providers, lack of privacy and comfort in clinics, as well as inconvenient hours and locations.

What if there was a way to expand the geographic reach of primary health care in a financially sustainable way, while at the same time creating environments that are hyper-responsive to the cultural challenges facing patients? A new model for health care delivery is uniquely poised to do that. In contrast to the traditional model that is centered around a limited number of primary care offices, this model is built on a network of various provider types (including health educators, nurses, nurse practitioners, nutritionists, physician assistants, psychologists, and social workers) collaborating with and supplementing traditional primary care. Using electronic health record management systems, healthcare is delivered in an integrated way, but in completely unconventional settings—including pharmacies, workplaces, retail environments (such as Target and Walmart), schools, homes, and mobile facilities. Additionally, care can be designed in response to the specific needs of targeted populations.

The model has been pioneered by the private sector during the last decade or so, but a handful of forward-thinking public health agencies are catching on. Among these is Alameda County Health Care Services Agency (HCSA) in California, which is creating its own network of comprehensive medical clinics, which it calls “health portals,” co-located on the grounds of public facilities. The first of these portals were established by HCSA beginning in 1996 and are known as “School-Based Health Centers” (SBHCs). The SBHCs in Alameda County have since become a national model for schools across the country. They are designed specifically for children, youth, and their families and are co-located on the grounds of schools, typically serving low-income communities. SBHCs deliver a range of care types including medical, mental health, health education, and youth development services. In addition to breaking down the physical and geographic barriers typically associated with health care, SBHCs also address economic limitations of many of the children they serve; services for students are covered by Medicaid or one of the county’s coverage programs, such as Health Pac. By the end of year 2012,HCSA plans to have opened 26 SBHCs throughout the county. The goal of HCSA is to provide accessible health care to every child in need.

Design, Healthcare, Public

Fire Station Health Centers Study, with example of siting study


Working with HCSA and its director, Alex Briscoe, Public Architecture is collaborating on the Agency’s latest portal innovation, known as the “Fire Station Health Center” (FSHC), which grew out of two events from a few years ago. In 2009, when the H1N1 virus hit, the Public Health Department was called on to quickly deploy immunizations to thousands of Alameda County residents. Looking for a way to efficiently administer the vaccine, officials turned to Fire Department staff for assistance. After all, Fire Department paramedics and EMT’s are well versed in pre-hospital care and they are located throughout the county. Working with them, the Public Health Department was able to quickly reach residents.

Later the next year, Briscoe was astonished as he witnessed protesters at a demonstration—who had been yelling negative comments at police—enthusiastically wave to firefighters as their fire truck drove by. Constantly looking for ways to increase primary care access, Briscoe and his colleagues connected the dots and realized a great opportunity. In addition to their medical expertise, fire departments are among the most trusted public servants—even in marginalized communities—and their facilities are in well-known, geographically distributed locations that often have underutilized space.

The FSHC model is designed to take advantage of these latent efficiencies by co-locating 1,350 square foot medical clinics on the grounds of fire station sites. Unlike traditional primary care offices or hospitals, which are often designed to serve a large geographic area and varied populations, FSHCs, like their SBHC counterparts, will be organized as a dispersed network of nodes that are individually sited and designed to serve very specific, local communities. In the case of FSHCs, target communities are low-income with high numbers of uninsured residents as well as high volumes of avoidable emergency room visits and sub-acute 911 calls. Literally every aspect of the FSHCs—from the service menu, to hours of operation, to the pricing model—will be carefully tailored to these populations.

With funding from the California HealthCare Foundation, Public Architecture has provided site selection and design strategy services to support these efforts during the FSHC program’s pilot phase. Our first stage of work was to develop guidelines to help the Agency identify a focus set of high-priority fire station sites, out of approximately seventy located across Alameda County. In addition to outlining basic spatial requirements for the sites, these guidelines helped the agency assess costs as well as the architectural implications (related to visibility, security, circulation, and visual identity goals) of co-locating FSHCs at specific sites.

Our work also included a second stage to understand the short-listed sites in relationship to their demographic and existing health care contexts. This information was compiled into a series of reports tailored to each of the six municipalities (Oakland, San Leandro, Fremont, Newark, Hayward, and Union City) in which the sites are located. The reports show physical proximity of shortlisted sites in each municipality to target populations, the physical constraints and opportunities associated with co-locating at each, as well as information about the health needs of the surrounding populations. They will serve as a tool to solicit the support and insights of city councils, stakeholders, and community members during the site selection process.

Public Architecture’s work on this project is an example of the ways in which design and design thinking can be leveraged to support public agency efforts to do more with less. In Alameda County, according to HCSA, as many as 200,000 newly-insured residents could be added to an already overburdened system by 2014, with the implementation of the Affordable Care Act. Nationally, the number of newly insured could reach 32 million.

While the amount of primary care is expected to grow in the next ten years, the new demand will outpace supply. Innovative programs, like Fire Station Health Centers, have the capacity to dramatically increase the supply of short primary care. The success of such programs will be determined by the degree to which the design of environment and experience can be tailored to the needs of the communities FSHCs serve.

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Brad Leibin

Brad Leibin is an architectural designer and writer in San Francisco. He is a Project Manager at nonprofit Public Architecture where he involved in the research, design, and development of the organization’s public-interest design initiatives and consultancy projects. He is, as well, a founding contributor to TraceSF: Bay Area Urbanism

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  1. avatar
    Brad Leibin

    I appreciate this interest and dialogue and I would like to respond to some of the questions that have been raised.

    @Roy: There are many reasons why fire station sites make a lot of sense. One of them has to do with the fact that they happen to be located within every Alameda County community that is in need of accessible primary and preventative care. With a goal of making the health centers as accessible and user-friendly as possible, this is important. Fire stations also tend to have very strong relationships with their surrounding communities. Finally, locating health centers at fire stations would leverage existing publicly-owned space.

    @Gary Wheeler: While it is true that ADA requirements are demanding, the designs for a 1,350 square foot Fire Station Health Center have been vetted with health providers to ensure that they can still be run efficiently, effectively, and under a sustainable business model.

    @Roberta Jorgensen: While the exact staffing model for the FSHC is still to-be-determined, it would not conflict with staffing for the fire station.

    —-

    I would also like to take this opportunity to acknowledge other people/organizations who contributed significantly to the development of the Fire Station Health Centers concept, as well as to the site selection process. They include RossDrulisCusenbery Architecture, Alameda County Fire Department, Alameda County Redevelopment Agency, Oakland Fire Department, Hayward Fire Department, and others.

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  3. avatar
    AG

    Its a great idea, but I feel that 1,350 sf local health clinics are not an architecture driven idea – they need to be health-care system driven in order to be maintained. Fresh ideas like this one could support decentralization of health care to provide more access, but I don’t think they can drive them. Is there really a market for these small clinics? If the County is opening 26 of these soon, they’ll soon find out.

    Most community health clinics that have proven themselves sustainable are 10,000 sf – 40,000 sf, like La Clinic de la Raza or Salud Para la Gente.

    My feeling is that is the ultimate health care ideal – to integrate health care into everyone’s lives – at the local level and even into the home – leading to effective public knowledge of health so that society won’t be saddled obesity and other avoidable health care problems.

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  5. avatar
    Roberta Jorgensen

    Since the example site plan shows the Health Center as a free standing building it would not have to be an Essential Services Facility. Looks like it is just adjacent, not really integrated. The rendering shows it as one building, but it could be designed to be structurally separated from the ESF. Fire Stations have always been mini-civic presences thoughout the community, so that part makes sense. I don’t understand how the EMT’s could (or should) do this on top of their primary emergency response assignment though.

  6. avatar
    Gary Wheeler

    Nice idea. But, impractical due to ADA reg’s. Any health care facility would have to have multiple handicapped parking spaces. NONE shown on the preliminary Perspective or Site PLan! Would also have to have a pair of handicapped restrooms. Any showers (there would also have to be two of them) would also have to be handicapped accessible. Then of course a pair of drinking fountains (high/low), a front counter that is “accessible” etc. One of the advantages of a fire station is that don’t have to be fully HC accessible because firepeople and police are exempt from some of the reg’s. Handicapped restrooms end up looking like dance floors because of the overlapping requirements for space, 5′ square space on swing side of all doors, etc. Sorry!

  7. avatar
    Roy

    what do the fire fighters think about this? Why a fire station? Why not a clinic in 1500 SF of unused retail shop space. Fire stations are almost always underparked. Additionally they are Essential Service facilities that are twice the cost of a non ES facility? EMT staff would not be able to double the duty since they are on emergency call 24/7.

    Does not make a lot of sense to me.

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