Good afternoon, everybody.

Today, we have Dr. Ray Pentecost joining us for the Architecture for Health Lecture series.

Dr. Pentecost is a director of the Center for Health Systems and Design at Texas A&M University.

So as some of you have already known him, he is the holder of the George Mohn chair in health care design, and he's also a fellow in the American Institute of Architects and a fellow in the American College of Health Care Architects.

He's currently serving as a global co-director of the International Union of Architects, the Public Health Group.

So please help me welcome Dr. Ray Pentecost to the podium.

Thank you so.

I'm going to swing around.

I thought I had it all figured out, but I don't want to block the view, so I'm going to slide around a little bit.

That's okay.

Y'all doing all right today?

Everybody good?

Well, today, talking about behavioral health, It's it's been a few years since I left practice.

And so rather than feature a case study today which has a few years of age on it, I decided to go back across several behavioral health projects that I did over the years in practice and lift out of them things that are important to understand.

Because if there was ever a true statement, it is that all behavioral health facilities are not created equal.

They vary a lot and sometimes in very subtle ways that matter a great deal.

So rather than feature a case study today, what I did was look across my behavioral health care projects and lift out of them the programing elements that distinguished them from each other.

And I thought what I would do today is just share with you those items as a way of saying, if you're interested in behavioral health, these are questions to ask and get good answers to from the client before moving forward so that whatever mold your facility takes, you've been asking the right questions to define it.

Well, everybody with me on that.

Okay, So I'm covering four general areas today.

First is we're going to look at issues related to the care model in behavioral health at at these facilities, second operations issues.

These are important things.

If you want the facility to run smoothly and they all have a little bit different model of operations, safety and security, you would expect that to be a priority topic in a behavioral health facility and it should be.

And then lastly, some issues that deal with design.

Now, in a sense, all of them relate to design, they all manifest in design.

You would expect that.

But in particular, there are some design issues that I want to bring forward for you to consider.

All right, everybody with me, we're going to jump in and start with the care model outcomes.

There are a lot of different outcomes when you're talking about behavioral health and your client ought to define those for you.

Are we entering this facility?

Never again to see the light of day.

Are we entering for a very short turnaround because the purpose of the visit is assessment only are we entering for therapy that we know is only short term?

Are you returning to society?

Are you going back home?

Are you returning home with technology?

Are you returning to the custody of police?

Did you come in as a forensics patient and returning to the custody of law enforcement?

Are you entering for extended care?

Sometimes that's the case.

And you know that right from the beginning.

So first thing to establish is length of stay or outcomes.

And the next thing that goes right with this is length of stay.

Why does that matter so much?

Because you got to know how many beds you need.

Now, if you've got X number of patients that you would expect in a year, you can take that number of patients and divide it by the length of stay.

That's that.

We want the building to never be more than 90% full because we might have a surge in demand or a busy weekend or some elevated demand in a two.

So the total volume and the length of stay number for different levels of care numbers of beds, percentage of occupancy, the length of stay becomes really an important factor and it becomes important in designing the kinds of spaces to stay in.

You wouldn't necessarily design the same room for somebody that's there for a week as somebody that was going to be there for four or five, six months.

So it's very important length of stay has to be part of the equation, especially in forensics.

You want to know what the forensic evaluation model is.

Is it quick in and out?

Is it long term observation?

Is there going to be some therapy, some intervention before release?

So length of stay and clinical model modalities Next, several modalities to to keep in mind.

And every behavioral care facility will look at treatment modalities differently, clinical modalities differently.

They'll have a different menu of services that are available typically in these facilities you'd find in O.T.

physical therapy and occupational therapy, if those are not familiar.

The short version is physical therapy is regaining the strength in your arm.

The occupational therapy would be learning to use your arm to dress or to eat.

So a simple distinction, but very important.

Sometimes the people who have a need for psychiatric care have experienced an injury or a limitation of function as a result of that.

Sometimes the psychiatric problem results from stroke.

And so there's a physical need for rehabilitation that goes with the need for psychiatric counseling or behavioral care, counseling, crafts, arts.

You want to be sure that they have something to do, especially the long term care.

Remember, these people aren't prisoners by and large.

They may be extended stay, but they're not prisoners for the most part.

So you want to have something that makes life in this facility bearable.

You want it to have some sense of normalcy, things to keep their minds busy, to keep their hands busy during the day.

So even woodshop greenhouses, you'll find all kinds of different things.

But let your client tell you what that needs to be.

Every facility is going to be different.

Every client has a different therapy model in mind for their population, so ask them to help define that.

Clinical modalities, recreational.

You got to have a gym fitness area.

You've got to have a place where these people can work out video games popular these days, theater, auditorium.

You got to make a decision about where and how many of these are.

These are going to be dedicated spaces or flexible multipurpose spaces.

What kinds of recreational therapies will this client want in their clinical model?

Clinical modalities.

Remember, these people are in for a while.

And so while they're there, they're going to need dental care, ophthalmic care.

They may need help adjusting their glasses, they may break their glasses accidentally.

They may need dental care to resume eating.

Remember, a large part of behavioral health therapy is going to be good nutrition.

You don't want a chemical or other kind of imbalance in the body to be contributing to the aberrant behavior.

So you've got to pay attention to that.

The clinical modalities, optometry, speech, hearing, speech and hearing is amazing.

You should spend some time watching speech and hearing therapists do what they do.

It's it is amazing to watch for that matter and what is as well.

But you can see the PTSD at work in front of your eyes.

What the speech pathologists are able to do goes way beyond what you witness.

They're reading the mind.

It's it's very different and it's amazing work what they do.

I don't think time allows, but the stories that I have from my years in the industry as an administration, the stories that I saw speech pathology do are just mind boggling.

They are they're amazing clinicians.

So that needs to be respected as well.

Looking at the population, think about the education needs in the population.

Is this provider, this developer of the behavioral health facility, going to provide education for the patients?

Think about the educate and level of the patients.

Are these well-educated people?

Do they know what's happening?

Do they know why they're here?

Do they understand the treatment model?

Can they participate in their therapy?

Do we need to provide classrooms?

What kind of teaching AIDS work in a behavioral health population?

Do traditional teaching technologies work?

Do they understand screens?

Would they be better if it was a tactile learning?

Would they be better if you were writing on a white board?

What's the teaching model in for this client, for this facility?

What's the best way to educate the patient to what's going on?

Informed consent.

Do we need to educate people about what's going on?

Are they capable of understanding informed consent to know what's going on and consent to treatment?

So consider the level of education in the population forensics.

This is a pretty important aspect of behavioral health.

There will be forensics in all likelihood in your facility.

Could not be, but in all likelihood there'll be some of that.

And you see forensics patients for a variety of reasons.

You'll see some forensics patients because they are a danger to themselves and they have to be protected.

They have to be put somewhere where they can be safe.

You'll find some forensics patients who are dangerous to others, and they have to be protected and the people around them have to be protected.

You'll see some forensics patients.

And this is one of the tragedies in behavioral health.

Some of the forensic patients are people that are homeless.

They're picked up on the side of the road.

They're picked up in downtowns, disoriented, confused, and they need a place to be, but they need some counseling, too.

It's really not fair to just warehouse them.

So we look for places to put them there will be decisions on competence.

Is this person competent to stand trial for the crime of which they are accused?

Does this person need continuing care clinically?

Is the problem that they are off their meds If we can just get them back on a regular meds problem, then they stop becoming forensic type patients and they become regular medical management patients.

Can we look for that in the forensics evaluation model?

Your client should tell you that intellectually disabled or intellectually limited people who are not capable of the 30 year old who does something wrong in society's eyes, who has the mind of a four year old, Do you treat them the same as a 30 year old who was thinking clearly when they did what they did?

How does your facility absorb this differential in a forensics population?

And then don't forget to there's a forensics component on the front end of somebodies experience with the law.

Are they capable?

Are they competent to to be treated in this manner for for the crime they're accused of?

But what about when they've done their time and they're ready to go back?

What about the forensics evaluation that says, okay, you paid the price?

The society said, but can we feel good about you reentering society, forensics and behavioral health are are inextricably linked.

And the link is something worth understanding when you have a chance to design one of these facilities.

Let's talk about age population.

Is this going to be a facility for all ages?

Is this going to be a facility for kids?

K 12.

Is this going to be a facility for adults, meaning 18 and up?

I've worked on a facility that was psychiatric care facility for geriatric patients only.

You'll find all kinds of age d limiters in designing for behavioral health.

So asking about population, age, population of the facility age, ask that question.

It'll help you know what to design.

Coed Sounds like an odd thing to say, but in actuality providers of care do actually raise this issue.

We were confronted with it on one of our larger facilities, a state hospital facility.

They absolutely said no to coed for forensics.

Absolutely not.

Do not mix those populations.

Gender separation all the way long term care.

We can see some mixing there in some cases, it can be therapeutic.

So ask that question.

Do not assume that you know the answer to that, although with forensics, you're probably safe to assume that the answer is not.

Consider the state where this facility is being developed.

Is there a statewide network of facilities?

Is there a state mental health plan?

Is there a state 5 to 10 year capital plan with other facilities plan?

I worked on a project, a state hospital, where the the clinicians said we can do a lot of things.

But one thing we absolutely want to do is create a new model of care.

And we are at the perfect time in history to do it because the state had just declared, We are not warehousing people in giant state hospitals anymore.

The state Behavioral health hospital will be a place for processing assessment treatment and then return to the communities.

The communities have said we don't want them, put them in the state hospital facility for too long.

We're going to put them back in the communities where family can get involved and neighbors can get involved.

And the visitation is not so burdensome to travel across the state to a state hospital to see a loved one.

So check to see what your state has rolled out or what they're planning to roll out.

You don't want to design a beautiful, brand new facility perfectly designed for the model that ends in that state next year.

That would be a tragedy.

So check that.

That's an important thing.

How do they intend to handle discharge staffing ratios?

This is critically important and an awfully easy thing to trip over in most states and for most types of care, long term acute behavioral, you'll find that the state licensing regulations have prescribed add staff to patient ratios.

And so if let's just make up some numbers for 24 patients, you need one half of a physician, one are in two LV ends, two nurse aides and three medication aides.

I'm making this up.

Let's say that's the constellation of clinicians that it takes to care for 24 patients.

And you come up with this mind numbing, beautiful design for 25 patients.

What you have to realize is that if you proceed with that, your client is left either with one room they can't use because the staff only can care for 24 or they start to use that 25th bed, but are forced to hire an entire additional staff team to care for that one patient.

And that happens, gang, that happens.

So before you go too far, check with your state for the level of care that you're being asked to design and find that staff ratio.

You don't want to make that mistake.

And I have been in the game long enough that in the area where I spent most of my time practicing, the ratio changed.

So it's not anything that you can learn once and say, I remember that.

I learned that.

You may have learned it most recently, but it could have changed.

So please don't let that slide by very, very important detail to get family.

You would think that family could be critically important to the healing process in behavioral health.

You would want that to be you might imagine that would be very important and maybe it can be.

Certainly you want to check that out with your client.

But imagine that mom is the reason son is in custody, because mom turned son in because son was abusing drugs and mom was afraid he was going to die.

Mom comes to visit and say how much she loves son.

Son looks at mom, come through the door and lunges at her in a rage.

You put me in here.

You did this to me.

You turn me in.

Don't assume in behavioral health, don't assume.

Family support is always wonderful.

It can backfire.

It can be a surprise.

You can't assume that.

And I'm going to come back to that a little bit later when we talk about safety and security.

But I'm going to keep rolling now.

And by the way, how many the role of family can be influential on so many things?

How many parking places that you need?

I mean, little details, How many places do you need where family can meet patients?

Are they private areas?

Are they confidential areas?

Are they public areas?

Are they supervised areas?

Lots of questions around family coming to visit.

You can even get very tied up in knots asking what door do they come through?

Is it the front door that says, welcome to the place where we bring healing, welcome to the place where people come to get better, too?

They come in a side door because there's an element of shame.

Have we brought mental health out into the public where we don't have to deal with that silliness anymore and people can face it?

Stand up.

What's the model in the community for this facility?

Just saying you need to check.

How does the outdoors factor into this thing?

If you're going to take the patients outdoors, are you going to secure them?

How much free rein do you give a patient if you take them outside, Do you want it protected from the elements?

Is it enclosed?

Does it have a secure perimeter?

Is it supervised?

Is it surveilled?

If you take them outside, is it part of the clinical care model?

Are there going to be sports?

Are they organized sports?

Are we going to have people fighting over the chance to be quarterback?

How are you going to manage the outdoors important?

And is it going to be part of the care model at all?

Dining.

How do you manage the dining experience?

Does everybody eat at the same time?

That seems in some ways like a formula for explosiveness.

That's right.

The last facility that I worked on, a state hospital, they deliberately said, We want where the patients live and where all the therapies happened to be separated by a long hall and along the hall We want staff.

We will want residents and treatment separated by circulation.

Why, we asked, seemed like putting them closer together, made a whole lot of sense.

It's time for therapy.

Well, it's just right next door.

They used travel as part of the therapy model to measure success.

Can you be told it's time for your therapy?

Go down the hall, turn left, find your therapy room.

Have it when you're done, Come back and find your way to your room.

It's part of the test, if you will.

Is the therapy working?

Have they progressed to that point, to that level of independent travel?

So dining is one of those things.

Therapy certainly is another.

But you want to make sure that you understand the dining model and by the way, are you fixing the meals or are you having the meals delivered?

Do you want a commercial kitchen, really?

And the staff and the maintenance and the expense?

You know, in health care, the meals are not all the same.

You don't fix for 100 resident patients.

You don't fix 100 meals that all look alike.

You've got people that can't have sugar, people that can't have salt, people that can't have red meat, people that can have this gluten.

You can't that can't have lactose.

You've got people that are on restricted calorie diet.

You've got all these custom made diets and kitchens in health care facilities are works of wonder to me.

They create all of these custom menus for people and get them out on time and and get them to the people who need them.

Are you prepared to offer that for the dining experience or is the food going to be custom prepared commercially and brought to the facility and in a warming tray or cart and then delivered to patients?

How is the dining experience going to be managed?

Important to ask.

Those models differ widely, and the cost differentials are significant.

In health care, you often hear the reference to the flows and generally speaking, there are seven.

A lot of people add an eight.

I've got all eight on the slides here.

We're going to go through them quickly.

The first slide that comes up is patients.

How our patients moving, I just alluded to that.

Are they moving from the room to the therapy, from the room to the dining, from the room to recreation, from inside to outside measure the patient flows to see if your design works.

You ought to be designing for the flow.

Remembering behavioral health is a design problem with extreme patient management requirements security, safety, control, very, very, very high priority items.

So patient for any of these flows become extra challenging in behavioral health.

Just note the seven one is patient flow, one is the flow of families.

How do they come in?

How do they get to the patients?

They're not probably not allowed back to the secure area.

Do you have a neutral ground where both meet or are they individual meeting areas?

Are they group meeting areas?

Are they supervised?

Is there a camera?

Before you answer that and and start thinking too compassionately, just imagine this irate son and this caring, caring, loving mother coming together for a visit.

And we don't have enough staff to put somebody looking at every encounter.

So we've got it on camera.

We've got surveillance.

Right.

And the camera operator sees this kid lunge across the hall at his mother and grab her around the throat and say, You did this to me.

You put me.

And how long will it take a camera operator to get help to that location?

How much damage can be done?

Think about that for just a second.

Somebody that's determined so flow.

How does patient flow family flow into and out of this environment and encounter patients?

Let's talk about providers, clinicians.

What happens when the nursing staff encounters somebody who's having a really bad day and flies off the handle?

Do they just say, now, now, or do you give them a path of retreat?

Do they have a secure, safe haven in the midst of the treatment area?

Is there a place where they can escape or how easy is it for them to call for help?

Do they have a silent alarm system that they where is it?

A is it an alarm system where they have to hit something on the side of the wall to trigger help?

What does the client want popular these days?

I'll just tell you, is the silent alarm where nobody knows.

The alarm has been set off except the people responding and they come like the wind.

They know something's up.

So that's something you but you want to discuss that you don't want to create an environment where the safety valve isn't properly considered and designed in either into the clothing or the equipment or technology.

But you want that considered the flow of medications.

Sometimes the medications used in behavioral health are pretty severe.

They're pretty intense.

You don't want those open to just anybody.

So how do they come into the facility?

How do they get from the facility to the dispensing area, the ones that are being used in patients in their residential areas, the ones that are being used in the clinic area for people who are receiving medical care, the people in forensic who are on diabetic medicines or who need medications to be able to think clearly, how do you distribute it?

How do you get those around?

And who is responsible for that?

How do they maintain custody?

Think about the flow of medications in the design of this facility.

Supplies seems innocuous, right?

We've got clean sheets, clean towels.

And yet, how often do we read of somebody who took the sheets and knotted them up and created the ability to to strangle themselves?

They are an innocent piece of linen can become the tool of ligature.

And you don't want to let that happen.

So as popular as decentralized supplies are in general, health care in behavioral health care is inviting somebody to do something unfortunate.

So it can't be the same.

It's a different mindset.

You've got to get your arms around that right.

You see that?

So how does this supplies flow through the facility to the secure areas and the less secure areas?

Information.

How do you maintain computing?

Do you have your computer on wheels?

Do you have it bedside?

If it's bedside, are the patients able to hack in?

These are very capable people.

How do you manage information flow through a building?

And I will say to you that no matter what you come up with, it's not enough capacity.

It will eat you alive.

Whatever you design into it, you'll finish the building and wish there was more guaranteed.

Let me just keep going.

The flows of equipment.

You've got a treatment technology that needs to find its way around.

How do you roll that Through the building?

Are the doors wide enough?

Are there sensors that get set off?

Are there tracking devices on the equipment?

Are there tags on the equipment?

How do you want to manage the flow of equipment and the tracking of it?

Discuss that with the client.

Lots of different ways to do it.

And then lastly, the process mapping process mapping is the eighth one and a lot of people point to this as a really important one, and we've covered the main seven, but there are little processes that need to be covered, a need for a patient to go over here and pick this up and bring it back.

Or what's the process for running that errand?

What's the process for bringing a family member in for a consultation with administration, not a patient?

What are these flows?

How do you manage that process?

And those flows pay attention to as many flows as you can identify and then check your plans.

Make sure they accommodate all of these different flows.

Accreditation.

You can't ignore it.

Accreditation is what authorizes these places to get paid and it will differ state to state.

So pay attention to that When you get the assignment, check and see what are the requirements for this to pass the accreditation inspection, whatever else you add or change or modify or dress up in your facility, you've got to include the accreditation requirements.

So for all of the duty of architecture, don't miss that.

The creative part.

Sure you want to do that too, but you've got to make sure that what you end up with the final product will work for the accreditation so they can be paid next lifestyle.

There are things for patients in these facilities that relate to lifestyle that you don't want to ignore.

They do need to go to the beauty shop, they do need to go to the barber.

They may have banking things that have to be taken care of that relate to the outside laundromats.

It's in some cases post office.

You may have things that are simply lifestyle issues and the client should tell you which of those need to be in your project.

You don't want to leave those out.

It makes being an inpatient more like being a prisoner than a patient receiving long term care lifecycle issues.

And I've got some to refer to technology.

What's the lifecycle of the technology in the building?

Some of it is going to be built in, some of it's going to be portable, the various types of equipment one, two and three or even four, if you include disposables.

But increasingly health care and general behavioral care in particular is moving to a tell a metric model where there's monitoring that you can wear that identifies location monitoring, that identifies vitals monitoring, that identifies whether you're taking your meds or not, monitoring that allows you to tell how a patient is doing, where they are, what they're up to.

And as we increasingly see the mega state hospital downsized and increasingly patients pushed back to the community to heal and recover and resume normal life, increasingly that tell a metric link is going to be more and more and more important.

So ask your client Are we building that linkage that tell a metric link into our care models because we're going to need space for that.

We're going to need technology and and i.t capacity for that.

Let us know right up front, build it into the care model conversation lifecycle on maintenance.

Predictably, these facilities are difficult to maintain if you don't put them the maintainable areas where they're easy to access.

Imagine trying to get to the air handling unit if it's right in the middle of the secure area of the residential part, you would put that area on a perimeter of the building where it's easy to access and easy to get to change the filters, change out a piece that went bad.

So simple conversations about maintenance, what are we going to do and how are we going to trade durability?

These facilities can be and historically have been facilities with extreme high abuse.

The facilities can be brutalized and you see that reflected now in the furniture that's available for behavioral health care facilities.

You won't see the soft and and fuzzy and and cushy.

You see much more durable, high durability finishes and furnishings and structures.

So be aware of that and have that conversation with the client.

Maybe it's not strong and durable everywhere.

Maybe it's only in certain places.

I'm going to continue to speak as quickly as I can.

It whatever you provide, it won't be enough, and I don't know how to tell you to fix that.

There's just increasing demand for it.

Know that going in, try to design for the ability to add it capacity anywhere you can surge.

We saw a surge with COVID.

You're going to see a surge in behavioral health and it comes in little pockets.

There may be a surge in a forensics need.

We got a bunch of people that need to be evaluated.

They've got to be in for the next three days or five days, and then we take them back to the corrections system.

But there will be surges.

And you need to think about designing a facility that can absorb alternate uses for beds for different kinds of patients that can happen.

Staffing, retention.

One of the projects we did in behavioral health was so high stress patients, the facility was spending a quarter of $1,000,000 every month on temporary help contract labor recruiting overtime.

It was a made 250,000 a month.

Now you stop and think for a minute.

Do the math.

That's $3 million a year.

What kind of staff lounge could you put in for $3 million every year?

Ask your client, How important is retention?

Do you have a shortage?

Would you like the facility to become a recruiting tool that can happen?

NAITO Health care is transitioning and behavioral health along with it.

The NAITO model in health Care says, look at look at the business world.

Businesses find a niche, build an audience, a establish trust with the audience.

And after that to offer other things.

Anything come to mind.

You remember going online where all you could buy was a book, and then all of a sudden that company could sell you everything on the planet.

Remember Amazon?

Do you remember going to get a cup of coffee?

And that was all you could get.

And now it's coffee and tea and pastries and breakfast and decanters and brewers and beans and grinds and everything you could think of.

They did the Naito model and health care is doing it now.

So look at behavioral health.

You trusted us with your behavioral health.

We had the state hospital.

But the new model is we're offering tell the medical consults.

Trust us.

We're offering other things.

Ask your client about embracing the NAITO model and broadening from the place where we locked up the people that had behavioral problems to the place where we go to get stabilized and return to the community for a more therapeutic regimen.

Patients You got to be careful about the safety and security.

They'll hurt each other.

They'll hurt themselves.

You've got to design with that in mind.

They'll hurt the staff, they'll hurt the visitors.

Not all of them, of course, but some will.

And you have to be discerning about that and you have to design for that possibility.

You cannot ignore it.

Safety of staff, Reasonable retreat.

I mentioned that already.

I won't be labor it.

But you really do need to think about the design.

It can't just be about the ease of staff, seeing the patients or reaching the base.

They've got to have a place of safe retreat.

By that I mean strong glass, strong locks.

It's a very special design concept explored and make sure you give it to them.

Safety of visitors.

I've talked about the mom and the unhappy son.

I think you get the point about how important that is.

Police visibility is important.

It's not something that you want to be painful and burdensome, but the visibility of the patient of the police to the patients and the staff is important.

We were told expressly make sure it's visible.

The secure perimeter safety and security elopement is patients trying to get out.

You got to keep that from happening.

But there's another problem.

Intrusion, the perimeter of intrusion.

Can you imagine a forensic patient and the gang that was wronged by this patient finds out they've been transferred to the psych facility for evaluation and that they break that perimeter effortlessly, find their way into the facility, or wait till they're outside exercising or whatever, and do the untoward so perimeter is not just about keeping people in.

It can all it must also be about keeping people out.

And you've got to be sensitive about that.

When you think about perimeter security, safety experts, they exist in behavioral health.

We worked with one.

His name was Frank Pitts.

There are others I worked personally with Frank, and to be honest, was astounded at his command of the information.

His understanding of the patient population and the facility implications that had to do with safety.

Whether it's Frank or someone else.

Those experts exist.

You need to get one.

It is a specialty and design all unto itself.

Don't miss the chance to tap that expertise in design.

Use research.

Here's an example.

In behavioral health, we're doing a hospital, and the model that they were abandoning was wards.

And they had, you know, 812, whatever the number of beds in this big ward.

And the theory, the prevailing theory therapeutically was that in behavioral health, by golly, you take these people that don't know how to act and you put them in the same room and they learn how to act, and you don't let them come out until they've learned it.

Sadly, we learned that that was a horrible mistake.

It didn't work at all.

What we've learned is and this is where research matters, give everybody a private room.

They know then that if things get too bad and they can't deal with it, they can retreat, they can go to the private room, catch their breath, collect their wits.

And they found that just knowing they had a place to go improved the socialization because they weren't afraid.

They knew if it got bad they had a place to go.

And so they blossomed.

Social by giving them a private place to live, not forcing them into communal living.

Research taught us that.

Please tap the research on design for health, especially for behavioral health designed for flexibility.

Think of this in the next slide.

Flexibility is a short term thing.

I've got a short term need for the next few weeks to switch the use of these beds.

You will have clients that need that make sure that your design can absorb an ebb and flow of patient use, switching from one use to another while maintaining security.

Now the slightly longer term view is adaptability, flexibility, short term adaptability.

We've put it in a framework where if we know that the mission changes and we need to modify the staffing and the clinical profile of the facility to fit maybe with a statewide system or a neighborhood community system of care, we've got a framework of a building that can be adapted.

So flexibility, short term adaptability, longer term.

I've got a slide now on comprehensive coherence.

This comes out of stress management, stress management research, and I'll go through a super quick because my time is up.

Comprehensibility Can you assess quickly the facility?

Can I know where I am, what's going on, What to do?

The next one is manageability.

If I can understand the situation that I need to get from here to there, can I manage it?

Are there barriers or can I make it?

Can I manage my way?

And the third element of this coherence model is meaningfulness.

Do I see in the furniture, in the behavior, the language, the clothing?

Am I being treated with respect?

Is it a meaningful experience for them and for me?

Can I comprehend my world?

Can I manage through my world?

And is it a world that makes me feel significant, fabulous watchwords for any building you ever build, but especially behavioral health, because the population is vulnerable to those things.

I think behavioral health is a blast to work with.

I loved doing these projects.

The clinical staff is creative.

They're caring in the extreme.

The patient variability is fabulous.

No buildings are ever the same.

So I encourage you, if you get a chance to work on behavioral health, grab it, do your homework, ask the right questions and enjoy it.

You'll have an opportunity to create something very unique.

Most facilities are unlike any others.

It'll be a trophy.

It's a beautiful, unique piece of architecture, meeting the needs of some very, very special people in very carefully designed clinical pathways.

Don't miss the chance to do that.

And with that, thank you.

Questions.

I know that you said there's no to say health care facility, but what are some of the overlaps that you noticed in terms of those different designs?

The question was if no two facilities are the same, are there things you can point to that are similar or the same from facility to facility?

Yeah, there are clearly common things.

Great question, by the way.

Security is always an issue.

Protecting people's safety is always a top priority, a desire to be clinically meaningful, full.

And that varies in specifics, but it is a mindset that is consistent.

Facilities need to interface typically in behavioral health.

They need to interface with state systems because it's very often it's commonly the responsibility of the state, provide that level of care.

So the state facilities and the community facilities that link to the state network, those connections become important.

Working with forensics and security, the interface with the corrections system and with the courts system, you'll see forensic patients coming in from lots of different places, but they all have to be treated with the same level of care.

You don't want anything unfortunate happening.

You don't want a breach of custody to happen, for example.

So in addition to managing the flow of all of those activities, forensic patients have to be managed in the security of the legal system, the court system, the corrections system.

You can't let them ever break that perimeter, whether that's, you know, theoretical or visual or virtual.

But you can't let them pierce that barrier all the care that they get.

You have to then maintain, in addition to all of the normal security, the security of the legal system and it's just the compounding of the complications, the layers of the challenge.

It's just a wonderful design problem.

It's a terrific challenge.

Yes I actually have two questions.

The first one being in terms of providing that security, not only to not let the patients escape and then people being able to penetrate through how do you provide security like but still provide an outdoor experience where they're able to enjoy, you know, nature and what have you?

That's a great question, isn't it?

That's why it's on the list.

The question was, how do you let people go outside for recreation or for therapy or just for breathing free and clear?

How do you do that and protect them from somebody coming in or from them getting out?

Typically, the outside spaces are confined.

You don't have to like that, but it's a reality.

They probably don't like jail cells either.

Those are very confining and if you want to give them exterior experiences, it is common to create a chain link, chain link fenced area or some other kind of constrained area.

Keep in mind there are lots of ways to create perimeters and one of the things that is really kind of wonderful that you can do with design is make the barrier real but not visible.

Meaning if you're outside in a play area, let's just imagine it's a field and on the perimeter of the field, you burned up right with landscape and some topography.

You built up a little bit of a mound and beautiful trees, bushes and flowers and, you know, it's a fabulous place to be outside.

But on the other side of the berm is this hard wall, this very secure perimeter that nobody can get through.

Well, I'd much rather be outside exercising and playing and playing a sport maybe, or just flying a kite and looking at this beautiful landscaped berm than a flat field with an eight foot or ten foot fence all the way around.

There are ways to do it that are respectful, therapeutic, caring.

You know, one of the things I don't think anybody gets into health care design that doesn't care.

One of the wonderful things about designing in health care is it's an outlet for those of us that really, really care.

And they want to believe that our architecture is creating place where people get better.

You know, that it's an outlet for that part of our hearts and in psych especially.

So these people are not only needing health care, but they're vulnerable in so many other co-mingled ways, you know, So to create places that are not offensive, that are not frightening, that are not scary, that's that's a worthy goal.

And there are ways to do it.

There are some really great ways to do it.

And then my second question is a little bit more technical.

I suppose if we were wanting to learn more about, you know, different regulation staff and patient ratio or just the plan for the state overall in terms of their like health care model, what would be a good resource to maybe start looking into that?

Every state's got an agency that does it and sometimes it's not automatic where you find them.

Sometimes the facilities piece would be under the care piece.

You know, you might find the facility components of mental health and mental retardation in the in the Department of Mental Health and Mental Retardation.

You might find their care guidelines in their models stay put and the facilities need to have .2.2.2. or you may find it over in the health facilities section of state government where they're authorizing the review of plans.

And here's a review mechanism for a hospital and a review for a nursing home.

And you know, that may be where the guidelines exist, but they all exist at the state level.

And and most people are willing to help you get them.

They want the facilities to not only comply for accreditation, but they want them to be therapeutic and successful and work.

I mean, nobody I haven't met anybody in the health design game that doesn't care.

It's the common you know, it's somewhere way, way back.

We all shared the blood of something or other, but we all have that running through our veins.

We all care deeply, and that's why we do what we do.

Okay, sir.

Thank you for a nice phone call.

It's thought provoking questions that need to be asked before you start designing the project.

Packaging broad brush.

Change in treatment.

Maybe for 600 1800 children have different philosophy, different methods.

Sure.

I remember back 16, 1800 years ago.

It was it was all new to me then.

Yeah, I could I can I can speak the big, big picture.

One of the very, very first mental hospitals in the colonies was in Virginia, and it was the Eastern State hospital in Virginia.

And I got to work on the modern version of that organization.

But in the early, early, early days, you can tour it.

They have tours of this early version of mental health and there was no therapy.

These it looks like the stall that you would put an animal in, you know, straw on the floor, hard wall edges, a barred surface across the front.

And they were Yeah, yeah.

There were some of that too.

If they thought you weren't safe.

They called that in the same.

So I don't know when that term came along George Insane asylum but the earliest versions they didn't know what to do with them.

It wasn't that let's be mean to these people it's they didn't know what to do and they knew that if left alone they could hurt people.

So part of it was a safety response and a lot of it was an ignorant response.

Over time, the blending of clinical models started to happen and there was the counseling piece and then there was the pharmaceutical piece, and then there was the surgical piece.

And all of these models started to swirl around the treatment and behavioral health.

One of the projects that we worked on as a firm had a reputation for being maybe the the number one hospital that did lobotomies.

And for those of you who may not know about that term, it's where you go in behind the eye with a tool that it's kind of curved and has a sharp edge and you go in behind the eye to a part of the brain that connects to the front lobe and you snip it, you just end it just very short.

Sweet.

Here, let me just flip it around there and the patient goes from a vital human being of reasonable thought and self ambulation to basically a zombie.

And it was perceived as a very straight forward, well understood way of intervening.

And the result was effective but tragic in the extreme form.

And these were routinely done.

The modern twist on all of this is we don't wear house like we used to.

The the preferred behavioral health model these days is a concentration of technologies and highly skilled people at a headquarters, kind of a hub facility with a network to community facilities.

And you think about what we're doing and tell them.

Medical consults with psych counseling.

The A&M is pioneering, really telemedicine in psychological care.

Our psych program, Carly McCord, is is leading that effort.

It's an amazing effort, the amount of telemedicine that they're doing.

But telemedicine, monitoring vital signs and monitoring falls and slips and monitoring nutrition and monitoring blood chemistry and that the tell a monitoring can take a patient out of a warehousing model and put them in the community where family and neighbors and loved ones can come see them and they can see a local provider.

It's a much friendlier network and it reduces the burden on the state of maintaining these massive warehouses of mental care capabilities.

So, yeah, in the old days they didn't know what to do.

It was a stall, basically.

And then more recently there were interventions that were brutal because they were effective and they didn't know any others.

And now the pharmacy, medical and surgical are working in concert beautifully.

And the tell a medical component has now begun to tease out of that hub those pieces that can be back into a residential community environment.

And the expectation, I think, and maybe even the early results, but certainly the expectation is that that setting is a more therapeutic one for the patient than the warehouse approach here too.

It's changed that used to be Uncle Love's insane.

And so now, you know, chemo takes his meds and and goes out on his job and there's a different there's a more enlightened way that he's made.

So it's true.

It's true.

And there's a bit of big difference.

You're right, George.

So you have to up the discussion because there's another class happening after this class.

So it should be all for me.

Thank you, Ray.