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Designing for Dignity: Evolving approaches to planning behavioral health facilities

By Vince Avallone, Kevin Day & Rebecca Kleinbaum Sanders  |  Photos by Bernard André

Clinical approaches to diagnosing and treating behavioral health and mental illness have been evolving over the past 20 years with ongoing improvements in treatment and medications. Often a misunderstood disease, mental illness is slowly losing its social stigma through greater public awareness and education.

Rather than treating all clients the same in large institutional settings, healthcare organizations are turning toward smaller-scale settings that address clients’ individual needs in the recovery process. Today’s newer behavioral health facilities more closely resemble the homes in which clients will live upon leaving. These smaller residences reduce social isolation and create a more natural environment as clients move through successive levels of care toward eventual independent living in the community.

The evolution of the mental health industry is following changes in the general healthcare industry, in which several clear trends are impacting the planning and design of behavioral health facilities, and in turn creating a more positive public awareness of mental illness.

The Affordable Care Act has brought mental illness up front. Mental health is now part of insurance coverage, giving more people access to services. Many healthcare organizations, likewise, are responding to the new reimbursements by including behavioral health services within their primary care clinics, further bringing mental illness to the public forefront.

Continuum of care

The healthcare industry’s focus on preventive care and wellness applies to the mental health industry by identifying the right level of service for clients along a continuum of care. Many clients enter the mental health system following a crisis, in which they are taken to an emergency department. Depending on the circumstances, clients undergo clinical assessment, followed by acute care treatment, then outpatient care and finally reintegration into the community.

The continuum of care identifies the right level of care in the recovery process and recognizes that each client is at a different stage depending on a number of factors. As such, many hospitals are adding mental health components or behavioral health-specific emergency departments to better address mental health crisis.

Outpatient care

With a general shortage of acute care beds, the mental health industry is placing greater emphasis on outpatient care, again aligning with the continuum of care to properly diagnose the right level of care at the right moment to move clients out of acute care and into transitional outpatient care. This is leading to a greater need for more outpatient facilities.

Comforts of home

Breaking down the institutional look of yesterday, many acute care units and outpatient facilities are adopting more homelike features that create a positive experience and restore a sense of dignity. Designing for dignity gives clients a sense of choice and control in their environment, while keeping them safe and comfortable.

Two behavioral health facilities illustrate how healthcare organizations are planning and designing for client dignity and choice along the continuum of care.

Homelike features at Hope House

Hope House, operated by Contra Costa County Behavioral Health Services in northern California, is a 6,850-square-foot, 16-bed crisis residential facility providing voluntary, step-down transitional care for clients leaving the hospital but still needing mental health assistance in a less restrictive setting. The supervised residential facility provides continuous assessment, individual and group treatment, peer counseling, medication evaluation and life-skills training for residents staying up to 30 days.

The facility projects homelike features that accommodate clients and their families in a soothing setting that lowers stress, promotes safety and improves outcomes. Typical residential features are replicated to provide a sense of comfort synonymous with home. These include:

Hardwood floors

Lounge furniture

Pocket seating areas


Carpeted bedrooms with operable windows

Community kitchen with breakfast bar


Expansive views to the outdoors and patio access

Other amenities such as a quiet room, group room, library and numerous indoor-outdoor areas for individual respite and group therapy add to the healing environment. The building is nestled within the contours of a hillside. The stucco-and-wood exterior suggests a lodge rather than an institution, which is appropriate for its wooded setting near a residential area.

Ultimately, Hope House is designed to shed the stigma of mental illness and restore a sense of personal dignity and choice.

Right-sized care at Cordilleras

Cordilleras Mental Health Center for San Mateo County Department of Public Works and County Health System in California is taking a similar approach with its recent feasibility study to replace a 117-bed facility, originally built in 1952 as a tuberculosis hospital.

Located on a hilly, wooded, semi-secluded 19-acre site, the center houses two separate treatment programs for adults with chronic mental illness: a locked 68-bed mental health rehabilitation center and a licensed 49-bed adult residential facility.

The feasibility study transitions the program into a series of smaller buildings that emphasize homelike settings, while capturing federal Medi-Cal reimbursements for facilities with 16 beds or fewer. More than just a design trend, healthcare research tracks a correlation between larger program size and longer lengths of stay. As the number of program beds increase, the residents’ length of stay increases. Smaller program sizes, however, often translate into shorter client stays.

As such, the study recommends building a total of six facilities, comprising five single-story 10,500-square-foot, 16-bed MHRC facilities and one three-story, 30,000-square-foot, 55-bed ARF.

The five independent MHRCs provide variation in the type of care appropriate to the population in each household. Each single-story house is further divided into smaller pods or neighborhoods of four bedrooms each, in which the clients have the freedom to move from communal space to more private space. Clients have an opportunity to “graduate” from the MHRCs to the ARF, which is planned above a campus center housing communal and administrative program areas.

Key to the study’s success, which proposes the project be built over multiple phases for completion in early 2020, is giving clients a sense of choice in their environment while maintaining security for them and staff. For instance, a careful balance between on-stage and off-stage areas for staff, and controlled access to the outdoors on the bucolic campus, was proposed.

Hope House and Cordilleras Center represent new directions in behavioral health facility planning. By emphasizing dignity and a sense of choice, clients can progress more successfully along the continuum of care. Tying in with the national trends focused on outpatient care, behavioral health facilities will continue to break down the institutional walls in favor of smaller, more homelike environments that recognize each client’s individual needs.

Author: Vince Avallone, Kevin Day & Rebecca Kleinbaum Sanders  |  Photos by Bernard André
Vince Avallone, AIA, ACHA, CASP, NCARB, LEED AP BD+C, is a healthcare architect and medical planner at HGA Architects and Engineers. Kevin Day, AIA, LEED AP BD+C, is a healthcare architect at HGA Architects and Engineers. Rebecca Kleinbaum Sanders, AIA, NCARB, is a healthcare architect and medical planner at HGA Architects and Engineers.

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Posted May 26, 2015

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