Behavioral health projects fuel healthcare construction and design

Massachusetts General Hospital had to expand to accommodate the growing number of children and adults going to its emergency department for mental healthcare.

The Boston-based hospital replaced its six-bed unit for psychiatric patients with a 20-bed unit. From there, some would be admitted to the inpatient psych unit, transferred to another hospital or discharged.

But during one day in February, more than 50 behavioral health patients went to Mass General’s emergency department, which meant that 30 patients were treated in the ED, a less-than-ideal place for someone in crisis.

The average daily census of psychiatric patients exceeds the capacity of the 20-bed psychiatric unit more than 50% of the time, said Robert Seger, executive director of Mass General’s emergency medicine department.

“We’re seeing a lot more pediatric patients, who tend to stay in the ED for a long time. It’s a national phenomenon,” Seger said. “We are in a new unfortunate frontier of many psychiatric patients seeking care at the hospital. The numbers are extraordinarily high, and higher than a lot of systems can handle.”

Many hospitals, limited by a lack of mental health counselors and psychiatrists, struggle to attend to behavioral health patients, who usually stay longer than acute-care patients. Residential care and other psychiatric-oriented outpatient facilities across the country have closed or reduced their capacity, shifting an even bigger burden onto hospitals.
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More than 70% of the 89 construction and design firms surveyed said they are seeing increased demand for a behavioral health component in their medical projects, according to Modern Healthcare’s 2022 Construction and Design Survey. Generally, the number of proposals has rebounded after stagnating or decreasing over the last two years, the companies said. The psychiatric add-on units funneling patients from the ED provide an immediate lift for providers managing a surge in behavioral health cases. Still, those short-term fixes aren’t expected to meet the demand.

“Behavioral health is a top concern of every major hospital,” said Sarah Markovitz, a principal at the architecture firm NBBJ. “Their EDs are overrun by behavioral patients, and they have nowhere to put them. It is definitely at a crisis level.”

Clicks and mortar

Health systems are renovating existing space, designating mental health wings in new hospital towers, designing flexible spaces and building stand-alone behavioral health facilities.

NBBJ, for instance, designed a nine-story, 386,000-square-foot behavioral health pavilion at Nationwide Children’s Hospital in Columbus, Ohio.

Construction firm Robins & Morton completed a 64-bed, 55,000-square-foot free-standing inpatient facility in east Tennessee—a joint venture between National HealthCare Corp., Tennova Healthcare and the University of Tennessee Medical Center. “This facility is designed to expand,” Robins & Morton Project Director John Galassini said. “Expansion is key for our clients so they can ramp up for higher demand in the future.”

Telehealth claims for mental health issues have skyrocketed, and in-person visits have experienced a similar trajectory. Mental health conditions have remained the top diagnosis seen in telehealth throughout the pandemic, recently reaching 61.2% of all virtual care claims, according to FAIR Health data. Meanwhile, the rate of outpatient visits for mental health and substance use increased on average by 13% per physician during the first 12 months of the pandemic compared with pre-pandemic levels, according to an analysis of 34,000 physicians published in January in JAMA.

“Treating patients with mental health needs requires a long-term solution that incorporates both brick-and-mortar and telehealth-equipped facilities,” Birmingham, Alabama-based construction firm Brasfield & Gorrie noted in its responses to the construction and design survey. A particular increase in such projects has occurred in the Southeast, the company said.

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As the stigma surrounding mental health continues to fade, more people will seek both virtual and in-person care. Telehealth visits often lead to more in-person referrals, stoking behavioral health construction projects. Still, heading to the hospital during an acute mental health episode remains the default.

One day last month, 57% of the ED beds at Chester County Hospital in eastern Pennsylvania were occupied by behavioral health patients. “Inpatient beds are really expensive. Outpatient services need to be in place so children can transition into supportive care, otherwise they will relapse back into the system,” said Daphne Corona, a project manager at architecture firm NBBJ. “Inpatient beds will continue to be at max capacity with the highest-acuity cases.”

More children are seeking behavioral healthcare, although access is limited by insurers’ narrow networks, low reimbursement rates and staffing shortages. When kids don’t get treatment, their issues often become more severe. They have to stay in the system longer as a result, which is why providers are dedicating large swaths of their capital project budgets to behavioral health.

“Behavioral health patients tend to stay longer compared with standard emergency department patients. When you look at the behavioral health patients coming to the ED, the pediatric patients tend to stay significantly longer than the adult patients do,” Mass General’s Seger said. “We’re seeing a lot more pediatric patients.”

Only about 1 in 5 children with a psychiatric illness get to see a mental health professional in the U.S., said Dr. Susan Swick, executive director of Montage Health’s Ohana House, a center for child and adolescent behavioral health at Community Hospital of the Monterey Peninsula in California, designed by NBBJ. Behavioral health access for children has likely waned as families have been locked in the house together, with drug and alcohol use increasing, routines interrupted, financial stresses mounting and loved ones dying, she said.

“We’ve seen an accelerated pattern of an increased rate of anxiety, mood disorders and substance use. Consequently, it is harder to access services,” Swick said. “People can’t get access to care, so they end up in crisis and come to the ED where they stay for days, if not weeks, waiting for a bed.”

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Ohana is a 55,000-square-foot, 16-bed residential and outpatient facility for children and adolescents set to open next year. The family-centered clinical program and construction were funded by a $106 million donation. Ohana sends child therapists to local middle schools to try to establish early intervention strategies. It offers a full spectrum of mental health services, including evaluation, treatment and prevention programs such as occupational therapy and art and music classes.

About 1 in 6 high school students throughout California considered suicide in 2020; 1 in 3 suffered from depression, according to the California Healthy Kids Survey. Nationwide, mental health ED visits increased 24% from April to October 2020 for kids ages 5 to 11, data from the Milbank Memorial Fund show. Such visits increased 31% for youth ages 12 to 17 during that time.

But commercial insurers’ reimbursement for mental healthcare provided at Montage Health has been inconsistent, Swick said. “We are eager to partner with insurers in the region who are crying out that they can’t access services for their customers’ experiencing mental health problems,” she said. “We are trying to demonstrate to insurers that paying for an intensive three-day workshop of treatment is more effective than coming once a week for an hour for 24 weeks and going into remission.”

Swick hopes that Ohana will resonate with employers whose workers will be more productive if their families are healthy. Then, the model can be exported to other cities, she said.

Staffing is another bottleneck. Ohana has partnered with California State University, Monterey Bay, to be a training site for social work students and has a track for unlicensed therapists to earn their clinical supervision hours, Swick said. “There’s a shortage of master’s-level therapists and doctoral-level psychiatrists and child psychiatrists. Recruiting in this region is also challenging, as this is an expensive place to live,” she said.

Outlook

Even amid staffing and reimbursement hurdles, mental health projects are expected to drive healthcare construction, experts said.

Institutional investors like venture capital funds are pouring more money into behavioral health projects than ever before, which will fuel construction projects over the long term, said Anosha Zanjani, behavioral health design specialist at Omaha, Nebraska-based HDR Architects.

“We are seeing a rise in construction for all aspects on the continuum of behavioral healthcare as we are lacking infrastructure in all points of care delivery for patients. We have a significant supply and demand disconnect as it relates to available beds and all types of behavioral health services,” she wrote in the construction and design survey.

Many projects were put on hold over the past two years, which has created pent-up demand, particularly for behavioral health construction.

“We have seen a steady number of behavioral health projects over the past 15 years,” Robins & Morton’s Galassini said. “But now we are starting to see a significant increase in request for proposals that have a behavioral health component.”

President Joe Biden in his federal budget proposed spending $51.7 billion to improve the mental health system, including $7.5 billion for workforce development and service expansion and $35.4 billion to enhance mental health access for Medicaid enrollees. His budget would require health insurers to cover mental healthcare with adequate provider networks as well as establish cost-sharing and reimbursement rates that are similar to other types of care. This could pave the way for more mental health projects.

“These policies could help healthcare systems overcome roadblocks like narrow networks and lower reimbursement rates compared to the cost of care, which historically limited access to mental healthcare,” according to the construction firm Skanska’s survey.

Meanwhile, more of the Nashville-based architecture firm Gould Turner Group’s clients are asking for swing units, which can adapt to a medical-surgical or psychiatric unit when needed, vice president and senior architect Matthew Griffith said.

“At every user-group meeting they ask for more behavioral health spaces than they typically would,” he said. “An ED expansion would usually have one or two behavioral health/psychiatric rooms or secure-hold rooms. They need a whole pod now. Sadly, I don’t see that demand going away anytime soon.

No list of design/build companies is available as not enough companies participated in Modern Healthcare’s 2022 Construction and Design Survey.

Download Modern Healthcare's Construction & Design Survey 2022.