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.
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.