Construction & Design Survey: Medical home model influences how designers build new offices

The patient-centered medical home is a healthcare delivery model, not a brick-and-mortar facility. But the members of a medical home's multi-disciplinary, coordinated-care team need a physical place to hang their white coats.

So the healthcare construction industry is working on medical office designs that facilitate medical home goals. Clinics and medical office buildings are being designed with more conference areas where multidisciplinary care teams can share ideas or meet with patients' families. Individual offices and closed doors are being replaced by open work areas that foster collaboration. And using Lean efficiency concepts, architects and designers are working closely with providers to create more seamless, patient-centered workflows that improve quality of care and reduce costs.

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A major benefit of an efficiency-enhancing design is that it can decrease patient-waiting times. That allows practices to decrease waiting-room size and free up that space for other uses.

But experts predict that more of these patient-centered medical facilities soon will be located in retail mall-type settings rather than in medical office buildings in or near hospital campuses.

The effect of the medical home movement on construction volumes is not yet clear, however. The 151 companies that participated in Modern Healthcare's 35th annual Construction & Design Survey reported that 2013 was a busy year on the medical office building front. But the numbers of MOBs built, expanded and renovated were not all that different from the numbers generated in 2012.

Survey participants reported completing 104 new MOBs, expanding 28 and renovating 218 in 2013. By comparison, the 169 companies that participated in last year's survey reported completing 110 new MOBs, expanding 25 and renovating 313 in 2012. For 2013, this year's participants reported starting construction on 63 new MOBs, 18 expansions and 92 renovations. That compares with 98, 18 and 92, respectively, in 2012. Also, 92 new MOBs were designed in 2013, as were 35 expansions and 167 renovations. In 2012, the numbers were 121, 21 and 158, respectively.

“We see things this year being pretty level with 2013,” said Deeni Taylor, executive vice president of Indianapolis-based MOB developer Duke Realty Corp.

Taylor sees two big design and construction changes resulting from the growth of the medical home concept. More meeting space is being added, as well as more wiring and materials to facilitate Internet, Wi-Fi and cellphone use.

He added that conference rooms are now included in the space that multispecialty groups allocate for their primary care doctors.

The trend is to get primary-care doctors and their medical home practices away from hospital campus-based MOBs and closer to their patients, said Scot Latimer, managing director at Jones Lang LaSalle's Healthcare Solutions Group in Evergreen, Colo. Integrated systems seek to create brand loyalty among members by providing convenient access and short travel times, he said.

He sees primary care moving into retail storefronts. “I think we're going to see much less (MOB) development,” Latimer said. “The development will be off campus and look and feel very different.”

Andrew Quirk, senior vice president for Skanska USA Building in Nashville, agreed. “Physical location is being turned upside down,” he said. “The concept of a medical home is really where healthcare is headed.”

Patients also want one-stop shopping, Quirk said. A prototype is Vanderbilt Health's One Hundred Oaks medical mall in Nashville. The outpatient facility is housed in a repurposed shopping center that now features 22 specialty clinics. “It's brilliant marketing,” he said. “You can see it from the highway.”

After signing a long-term lease in 2007, Vanderbilt began moving in clinics, starting with women's health, then dermatology. “Primary care was relatively late in the migration process,” said Dr. Rob Hood, medical director for One Hundred Oaks. “This is not exactly the same as a medical home.”

Despite the differences, Hood noted that One Hundred Oaks offers patients the chance to see multiple physicians in one place, and have imaging and other tests done on the same day as their doctor visit. Other conveniences include parking spaces no more than 25 to 50 yards from each specialty area.

Multidisciplinary collaboration—another principal element of medical homes—was a cornerstone of the One Hundred Oaks project, both in the design and construction process and in the final product. Early on, Hood said, regular meetings brought together physicians and administrators from each clinical section. Complaints were aired, suggestions were offered and announcements were made.

The facility has plenty of meeting spaces, including several 10-seat conference rooms that can be used by community groups and a conference room that can be configured to seat 85 people for major presentations. The rooms are equipped for teleconferencing with the main Vanderbilt campus.

But other providers are going for a purer form of the medical home model, said Dr. Andy Ellner, co-director of the Harvard Medical School Center for Primary Care. Many new medical home offices include quiet areas for private phone calls and “touchdown spaces” which serve as a hub for the multidisciplinary care team to have short consultations with each other.

At the Center for Primary Care, Ellner works with physicians, residents and medical students to foster innovation at 19 physician practices that see some 275,000 patients. He said a key barrier to medical home transformation is a reluctance to give up individual office spaces. Still, ideas about what constitutes the ideal physical space for the medical home model are evolving. “We are not at the point of standardizing—we have 19 practices and every one is different,” Ellner said.

One of the 19 offices is the Dimock Center in Boston, where Dr. Julie Tishler practices internal medicine. Tishler said work at the Dimock Center is organized so the multidisciplinary team comes to the patient rather than having the patient travel from room to room to see each type of professional.

How we did it A total of 151 respondents participated in Modern Healthcare's 35th annual Construction & Design Survey.

This year's total includes 77 architecture firms, 32 general contracting firms, 25 construction management firms, 11 development firms and six design-build firms that were eligible to be ranked.

Announcements and reminders for participation were sent via e-mail and made available online at from Dec. 3, 2013, through Jan. 24.
The Dimock Center will almost double its footprint, with an office renovation planned that will expand the space from 4,700 to 7,000 square feet. In the meantime, Tishler said patients have been surveyed to gauge their attitudes toward different chair configurations in the waiting room and small touches like using a white board to list delays individual doctors may be experiencing that day.

A lot of attention was given to issues such as exam room layouts that help clinicians maintain eye contact with patients.

Architect Ken Duncan, in the Tulsa office of the Dewberry architectural, engineering and consulting firm, said small elements that create waste in a medical office can add up to a lot of time and money. Duncan advocates using Lean methods to design patient-centered care facilities that eliminate wasteful and inefficient processes.

Efficient facility design can streamline care delivery. Duncan used Lean methods—both in the design process itself and in the final plan—to create physician offices for St. Louis Park, Minn.-based Park Nicollet Health Services.

That process led to building a simple physical layout that allows patients to find their own way to their exam room without having a medical assistant or nurse escort them. While accompanying patients to a room may only take two minutes, if multiplied by 25 patients per doctor and eight doctors, that can eat up a full-time staffer's entire work day.

Charting the patient's experience, from the patient's point of view, is a good way to work on the design, Duncan said.

Follow Andis Robeznieks on Twitter: @MHARobeznieks



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