Planning the path to success for micro-level behavioral health design projects
Behavioral health continues to receive increased attention from patients, health systems, the media and government. The challenge of providing safe, accessible, dignified, and affordable mental health in Milwaukee County has been a longstanding issue. The need for a new behavioral health crisis center remained a community need. Milwaukee’s Mental Health Emergency Center (MHEC) was envisioned as a micro-hospital crisis center. The process led the design team to identify several differences between planning medically focused micro-hospitals and the behavioral health focused MHEC.
Provide Easy Access While Understanding the Neighborhood
The micro hospital approach allows patient care to be delivered close to patient’s homes and away from the typical medical center campus. However, the notion of a behavioral health crisis center can invite a NIMBY or “Not In My Back Yard” response in many neighborhoods. There are always concerns with increased traffic and siren noise from emergency vehicles. In the case of behavioral health crisis center there are added concerns with police presence and agitated patients. Leadership needs to understand the risk of having neighbors object to the project and should take steps to minimize objections. On a recent project, site selection targeted the neighborhoods that use the existing county facility, and an extensive site selection process evaluated over ten sites in the target area. The selected site met the criteria of being in one of the target ZIP codes, separated from residential and education institutions, and having public transportation and freeway access to the rest of the county. Project leadership worked closely with community leaders to build approval for the project. With grassroots support, questions at a community virtual town hall focused on the services the community wanted rather than criticism of the building in their community. Support at the neighborhood, community, city, and county level resulted in a smooth approval process.
Separate Each Patient Cohort
A behavioral health crisis center functions as a triage center for people in crisis and serves to assess, evaluate, and treat as an outpatient center, while allowing patients to transition to a short-term inpatient stay. The behavioral health setting requires more attention to separating patient cohorts. Separation is important for patient and staff safety. At a high level, clear separation is achieved by arranging staff and patient areas in two distinct planning zones. Safety concerns require separating adults and adolescents as soon as possible, upon entry. Separate adult and adolescent intake areas would be ideal. However, the compact nature of a micro-hospital model will likely lead to a single entry that separates adults and adolescents after initial intake processes are completed.
Patients can arrive either voluntarily or involuntarily. Voluntary patients need a welcoming and open arrival experience. The voluntary entry needs adjacent parking and access to public transportation since many patients may lack the means for a car or family who can bring them to the facility. Similar to an emergency ambulance entry, the involuntary entry should be distinct and separated from the voluntary entry. Involuntary patients typically arrive with multiple law enforcement teams or social workers. A third site security factor is the staff entrance and may include a gated staff parking area and secure path to the staff and service entry. Three entries for a relatively small building means additional site area is needed to accommodate the various vehicle circulation paths.
Security drives the site and interior planning and establishes the overall concept that places patient care areas on one half of the plan and staff and support areas on the other half. Security needs within each patient zone focused on anti-ligature features and direct observation of patients and staff. A central, team work area gives staff access to the crisis center milieu and inpatient dayroom while keeping the patient types in distinct cohorts. Staff have clear sightlines to patients and patient room doors as well as their colleagues who are engaging directly with patients. These clear sightlines improve safety and security by ensuring everyone can be seen and supported. The distinct separation of staff and patient areas also allows staff to step away from the intense activity of the patient care spaces for breaks, team consultation and support activities.
The micro-hospital model requires cross-trained staff for greater flexibility and efficiency. However, compared to a traditional micro-hospital, a behavioral health crisis center requires more space for patient and staff separation, security, and circulation. The desired separation and security needs required a circulation factor that was 8-10% more than a typical micro-hospital. However, the increased circulation is offset slightly by the six-foot-wide corridors allowed in the behavioral health setting. Even though a narrower corridor is possible, it is not always ideal, and staff may prefer a wider corridor for increased patient separation and room for patients escorted by multiple staff. Corridors can open to program areas like the dayroom and milieu to increase the perceived room size. Inpatient room sizes in the micro-hospital model are minimal due to the short stay. However, a high circulation percentage is still needed to maintain clear lines of site to observe patients from team areas. Staff support areas should be planned with maximum flexibility or as shared uses. Early understanding of the clinical support needs can help the team design the most efficient support areas. One challenge of a compact plan is maintaining access to views and daylight which are an important aspect of any healing environment. Views to the exterior are challenging to maintain while allowing views to each patient space from a central care team area. In the case of the MHEC, a distinctive roof monitor marks the separation of patient care and staff support areas while brining much needed natural light into the milieu and dayroom.
Planning a behavioral health crisis center as a micro-hospital requires a robust understanding of the operational needs. The challenges require an added level of detail and complexity that goes beyond a typical micro-hospital. The end result is the ability to deliver critical crisis care services to the community in a safe and efficient care environment.
David Groth, AIA, EDAC
Senior Design Architect
Medical Construction & Design