- I grew up with a father who was a primary care physician at what's called People's Community Clinic, which is a federally qualified healthcare clinic in Austin, Texas.

And I remember firsthand him telling me stories about the importance of meeting people where they are.

And one story really sticks out to me about a patient that he had.

It was a, you know, middle-aged gentleman and his wife.

He'd had a heart condition and it was really well managed.

They had a home, car, and the problem was they just couldn't afford the expensive heart medication one month.

And this happens all the time.

And so he was up on a ladder fixing some part of his roof, and he fell down because he had a heart attack and ended up in the ICU, ended up basically having this extended care, right?

And because of that, he did not have the ability to cover his insurance, and he and his wife ended up homeless.

And I think it's always stuck with me how extremely unfair something like that was, that just because he couldn't afford a simple medication and the system wasn't meeting him where he was, then it created this whole other life for him.

And that, for me, is the reason why I am overjoyed, honored, and privileged to serve as one of the architects of Waco Family Medicine.

I am Erin Peavey, and I am an architect, a researcher, and a Health & Well-being Design Leader for HKS, and I am so excited to be here with my colleague, Hannah Shultz.

- Hello, I'm so happy to be here.

- And you can see just a section of our amazing design team that went into creating the project that we're about to share with you guys today.

This does not include the whole range of different people from structural engineers, landscape engineers, and architects, civil and beyond, but we're just gonna share with you a little story of this project, how it came to be, and some of the things that we think really make it special.

So we're gonna share really quick the learning objectives with you.

Then, we're gonna go over sort of what it looked like to do visioning and planning.

And that was a really special and wonderful time that is critically important for the rest of the project implementation, and then we're gonna open it up for Q&A.

All right, so not gonna read all of this to you guys, but feel free to read it.

Really, we're gonna talk about four main themes.

One is community engagement, how we engaged with the community, specifically.

That included the leadership of the clinic course.

It also included the Patient Family Advisory Council throughout the clinic.

And it also included going there and being with the broader community as a part of a community health fair and listening to about 100 different people throughout that experience.

So we'll share a little bit about that with you guys.

Then, we're gonna talk about something that you guys may have heard of before, but essentially, is how the built environment, you know, the architecture, interior design, landscape architecture, all of that, the physical spaces, can be what's called a social determinant of health.

And so we'll get into that.

And we're also going to be talking about the importance of what's called integrated clinical care model and specifically why that is so important for the outcomes, the health outcomes that we're talking about.

And to get back to that story of my father's patient, it's really about all of these things working together.

And if they had more of that, then they're able to help to serve this patient population.

And then hearing the design, execution, and process, where we integrated wellness and holistic care for the patients, visitors, and for staff.

So Hannah's gonna tell us a little bit about the site, just to give you guys some context of where we are, and then we'll dive into some of those things.

- So the community surrounding the current building for Waco Family Medicine involves some single-family residential homes and also some commercial buildings and businesses, as well.

Here in the center with the red dashed line is the existing property boundary for where the clinic is now.

And then off to the right here is MC3, which is also part of their clinic operations.

And they share this plot with a senior residence facility.

And so thinking about this main street that is right in front of the clinic, there's a lot of businesses and vibrancy just down the road to them.

It includes a market, some restaurants, a little theater.

And so this, from the get-go, was something really important for the design team to understand.

Who is around currently?

What does that look like?

And so the design team looked at a variety of options for a new clinic and how that might fit on the site.

But realizing that the clinic itself, they couldn't afford to just build new, and you know, build a temporary option, they were gonna have to stay in their existing space while the new one was being designed.

So the design team had to think about how a future building was gonna fit on the site, knowing that the existing clinic was gonna have to stay.

And so we'll get into that a little bit later about those exact design responses.

But that gives a little bit of insight from the get-go, what the design team was thinking about.

- Great, thank you.

So we understood those constraints, and we really wanted to help them.

You know, when you start a project, that's sort of like mind melding with your client and with the surrounding community, and part of that is really happening in project visioning.

And so here you can see the CEO, who's a fabulous individual named Jackson Griggs, Dr. Jackson Griggs.

He's looking at these different design options and sort of resonating with what he is drawn to, or you know, what feels uncomfortable to him.

And so then, essentially, having this be an exercise that they're able to do alone, and then you start to sort of ask questions and open them up.

So that's one thing, and that's sort of like when we think about visioning from an aesthetic lens.

There's also a type of visioning that we did as a part of this that, you know, is less maybe visual, but is really about listening, listening to the words, listening to how you want people to feel when they come here, how you want the future of Waco Family Medicine to serve the community.

And so you'll see how these led into our ultimate vision for the project.

This is a fabulous group of people that we were able to meet with and do a very similar exercise.

You can see all the boards up on the wall.

This is the Patient & Family Advisory Council, spending a few hours with them, providing food and just saying, like, "Let us listen to you.

Let us ask you questions about your experience and how we can make this a better experience for you in the future."

And through all of those meetings, we came up with this, the project vision statement.

So that was to create a clinical home that warmly welcomes vulnerable people in the heart of Texas to support patient-centered, affordable community health that fosters staff joy, and advance education and research across the clinical spectrum.

And I think each part of this was really important.

They were so big into the warmly welcome.

That was in their ethos and in everything that they sort of talked about.

And that project vision statement helped us to make our decisions throughout, as well as this, our project core values.

So hospitality, that's really about that, like, Southern hospitality, that warm welcome of creating an environment where all feel welcomed, comforted, and cared for and valued as an individual.

That integrated care component, right?

That comprehensive primary and preventative health that empowers the patient and the family as a part of a care team.

The clinician joy, so could go into this forever, but there's so many different resources about why this is so critically important and the ways that we've sort of forgotten about this throughout our process.

And I think that, really, you know, that's a whole nother talk, but clinician joy is incredibly important.

And this comes from the literature.

So support the joy for the work of clinicians, residents, students, and faculty.

And then to have financial stewardship, of course provide affordable, high-quality care at a place that supports both first-time investment and long-term growth.

And then, ultimately, to create an elevated presence.

And so that was really important to sort of put Waco Family Medicine on the map, allowing for their future growth and continued care excellence.

And so this is what I was talking about with the community engagement.

So we sort of said, "Okay, we understand that these are some of the things that we're looking at now."

Really, like, what does this look like?

What does the community wanna feel?

What do they wanna see?

And so we had these boards up that really were both in words and in images.

We sat there and talked to the community.

We had about 100 members come through, a ton of children, older adults, all sorts of people.

And the thing that I love about this was not just, you know, so we went, myself and another individual that was fluently bilingual, had Spanish as a first language, went together, and we were able to engage with a whole host of different people, and really talked to them, and really listened to them.

And out of that, actually, a few days later, I think this was on a Saturday, and on that Monday, we had the leadership of Waco Family Medicine come up here for our first real design charrette, where we were talking about the siting of the building.

And so, you know, Hannah showed you that image earlier.

So this is what we finally ended with, because basically, we tried options that were really linear in one direction or in the opposite direction.

But we noticed that, essentially, all of of the community, they were saying, you know, "It's really stressful for us here.

Having some sort of a green space would be really wonderful to help us like calm down or to help the children."

Like, they'll spend a decent amount of time there, right?

Because it's sort of a one-stop shop, right?

There's diagnostics, there's pharmacy, lab, and clinical care, all of these things all in one location.

So being able to go outside allowed them...

So basically, like, the CEO was like, "Well, what if we angled this, right?

What if instead of, you know, right or left, it was a 45-degree angle?"

And that really opened up this sort of gift back to the community of this beautiful green space, this little gem, that activates the rest of the business corridor and connects a lot of things to one another.

And so yeah, it was really beautiful to see how one thing could lead to another and really transform.

- And I think one thing I wanted to add on that last slide, Erin, what we'll get into a little bit later, but I love how the angling of the building creating that corner of green space also breaks it apart from the rigidity of our typical streets, and it refocused the main entrance.

So as you're coming along Colcord to the East, like, it starts to envelop this front porch.

And I'm getting ahead of myself, but yeah.

- No, that's awesome.

I love that.

Yeah.

And like, and even by breaking it apart the way, you know, that we did, I think all of that was really about making sure that it felt at a smaller scale that fit within the existing community.

So I loved everything you just said, Hannah.

That's awesome.

Okay, so these are really our learning objectives.

We've just talked about community engagement and sort of some of the ways that we've seen that.

We're just scratching the surface of all the things that we did, but that's the time we have here together.

We also are gonna be talking about social determinants of health, integrated care teams, and integrated wellness and holistic care.

So let's start with the social determinants of health.

So for anyone that hasn't heard of this term before, a lot of times, when we think about health, you know, like what determines our health, we might think about clinical care, usually.

Sometimes we think about diet and exercise, maybe you know, medicines.

But really, the whole host of things that you see here are what are included in what's called the social determinants of health.

So everything from social and economic factors, healthy behaviors, clinical care, and even the physical environment.

And so a lot of times, so like this is a diagram that we created a number of years ago with the Center for Health Design, and these are indicating the large models that sort of look at what percentage different things are accounting for.

And while the physical environment is typically considered 10%, that's considering things like housing, water quality, and healthy materials, we understand that there's a whole body of research that sort of shows how the physical or built environment impacts not only that but also clinical care, how where the facility is located is going to, you know, impact ease of access and quality care, where the facility is located is gonna be how easy it is for people to have healthy behaviors in and around that to choose healthy.

And you'll see how Hannah will help guide us through what that looked like when it showed up in the building itself.

And then social and economic factors, all of these things are being determined by components of the physical environment.

So I think it's important to never forget what an impact that you do have.

And these are some of the examples.

Hannah, do you wanna share some of these examples here?

- Yeah, so, and we'll see what this looks like in planning, but some of the social and economic factors like how that translates to the built environment, that included just having flexible space that helped to support their operations and like their clinical model for providing legal fairs, wellness fairs, bringing in other critical players, basically, for a full and healthy life and hosting that on their site and within their building.

That also includes the community lawn and having a place that's safe in the community, that's welcoming, where you don't just enjoy it whenever you go to your clinic appointment at 8:00 AM on a Monday, but also on Saturdays, you can go and throw a ball around and just lounge out there.

And this also is transponding to the healthy behaviors.

So they have a gardening and a teaching kitchen program, where they grow herbs and some vegetables on site just right outside the community lawn.

And then they're able to cultivate that, grow it, and actually bring that into a teaching kitchen.

And so those are just like a few simple ways that they are clinically and operationally already doing this as part of their services, and we just had the joy and privilege to actually help support that in design.

- Ugh, love that.

Heck yes.

Okay, lemme see if I can find this mouse again.

All right, so for integrated clinical care, so really, a patient... You guys may have heard of the concept of a patient-centered medical home.

If not, don't worry.

Google can help to answer some of your questions.

But essentially, it's the idea of a home, it can be both a physical space, but in a lot of ways it's a concept, right?

To say that everything revolves around the patient or the patient and their family.

And so really, you know, understanding that each one of us may have this whole host of needs of care and that that clinical care team needs to talk to one another as well as to the patient and to their family that are helping to be the extended caregivers at home.

And why this matters is because integrated clinical care and the ways that a federally qualified health center work actually help to improve patient experience, increase staff satisfaction, and reduce healthcare costs, because they help make us healthier, so they reduce costs.

And what this looks like, you'll see a lot of different things, and Hannah will sort of walk through some of, like, basically looking at it from a floor plan level, but shared spaces, adjacencies, and team collaboration are really critical.

Also, having this component of integrated wellness and holistic care, right?

Like, this vision of having this be a health hub for the community, not just a clinic by itself.

And so this really helps to demonstrate and foster healthy living, helps to increase health and well-being, and these experiences of community connection, which we understand are vital to our physical and mental health, right?

We are meant to be in community with one another, and there's a lot of the education and programming as Hannah spoke to earlier.

So take it away, Hannah.

- All right.

So talking about the design execution, we're going to start a little bit high level, and wanna go to the next slide.

So looking at the stacking of the building, I think we could probably also go back to some of the site forces that impacted the building massing that we alluded to earlier on the site plan.

But we wanted to address community, we wanted to maximize the views that could be had from the clinic and from this large waiting and lobby space and also infuse these points of biophilia, nature, and just some really nice green space.

And so what that looked like in the stacking is this level one, having this large front porch and family market area.

And so this whole part includes some of the like basic imaging services, lab, things that are quick touch and to be easily accessible.

And then moving up the building with level two, that's where the admin is going to be.

Places that, you know, are more just like staff working spaces, but still wanting it to be, you know, approachable and to help connect between public things that are happening on the ground level and then clinic services above.

So level three and four are the clinics, and that also includes a dental component, as well.

And so looking at the site and how the building is to be oriented, in that bottom right corner is that large community park, and that large green space just to the left is that main entry.

And so that's what we mentioned earlier about, you know, reorienting the building so that as you're coming along Colcord, you can just see just the main presence of the building.

And on the bottom left is that view where you start to see this front porch that is starting to expand from the main building and just helps to invite people to come into the lawn, come up to like this large porch area with chairs and really becomes this fluid space for community events and engagement.

- And I would just add, I thought that was really nicely said, and I would just add that, you know, where you see this little logo here, this is some of the sort of idea for outdoor exercise, because the physical therapy rehab gym is right inside, and it is really meant to be welcoming to the entire community, not just patients specifically.

- Moving inside, I'm gonna talk a little bit about how this public wellness corridor and this access flows through the interior.

So the main entry is on the south side, and you immediately open up into this expansive lobby that is part of a two-story height space.

Off to the left, whenever you first come in, is those critical functions like their eligibility service, billing services, and pharmacy, things that are gonna be really quick touch.

So right off the bat, it's easy to kind of orient and understand where you are at for some of those key services.

And then moving a little bit deeper in is part of that centralized family market.

And so this helps to support some of those marketplace services that they offer where they bring in WIC, legal counseling, gosh, a ton of other different types of counseling type services, and it gives them flexibility over time to kind of shape this space as they need.

And you can kind of see this in the bottom-right corner, where the lobby space is opening up with this two-story glass that's looking off into this porch area and then the community garden beyond.

- And I'll just add one thing about that, how Hannah was talking about the sort of spaces that add some flexibility for different types of counseling.

One of the things that we see happening, oftentimes, with community clinics especially, but I think, you know, is a model that I've seen other places, as well, which is essentially, you might have a specialist that would volunteer a day of their month or of their week to come in and do a certain type of thing.

So this allows for that sort of flexibility to have it open sort of like a conference room in a workspace, right?

You understand that there's a bunch of different types of needs, but that all of those can sort of happen in a shared space that is gonna be owned by different people at different times.

And so most of these will rotate who uses them, but for the heavy users like WIC and like legal services, those may be more consistent.

So I think that's really offering that flexibility, both over the life cycle as well as for the short term.

Sorry, continue.

- That was a really great clarification.

Yeah, and then moving up to more of the north side of the plan, we have the teaching kitchen, or we're calling it a culinary classroom, and just out to the right side of it is part of that culinary garden and just entire healthy food, nutrition, lifestyle behaviors that they're trying to help teach people.

And so with that, it's one of the first things that you see whenever you enter the building, and it really helps to support just the whole process of getting to know how to cook your own food and just some really healthy lifestyles.

And then to the north side of the plan is the wellness gym.

And so what's really unique about this wellness gym is that it's not only for patients.

Oftentimes, staff are also using it.

And so having this be front and center right off the main lobby right outside the patio space and having outdoor space that can flex so you can use the gym on the inside, go outside on some nicer Texas days when it's not too hot, really helps to send a message to the community that health and well-being, both with what you take in with the culinary kitchen and then how you use your body and movement, is a huge part of wellness in general.

So yeah, I think that about covers that.

And then, okay, so we talked all about this front, public side of level one.

A big component of this is also some of the clinical services, and so thinking about ease of access, ease of wayfinding for those typical services that you might get when you get a checkup like lab, maybe some updated scans with radiology, we were really wanting to have those be easily accessible and just to help clear up any wayfinding.

And so you'll kind of see a little bit towards the north patient access, that's the main entry for both lab and radiology, and keeping the interiors, kind of like that image that you see, to be as warm and as inviting as possible.

'Cause we know that, you know, sometimes it's not really that fun to get imaging done and to have blood work done.

So we wanted it to be as warm and welcoming as possible just to help it be a little bit more familiar, too.

And so that was, it's part of like the main patient flow whenever you arrive.

And then also, thinking more about the staff side of things, having a space that's just for staff to take a break, to find some respite times, 'cause we all know clinics can be very, very busy.

They've got a lot of things to do from when they open to when they close up, and it is difficult to get a break.

And so having a dedicated staff-only lounge and then staff patio is a huge part of Waco Family Medicine's foundation about caring for their staff and sending a positive message about "Hey," you know, "We care about our staff, and when we care about them, it helps them take better care of you."

And so it was a lot of fun to think about, you know, how we can enrich that space for them.

- All right.

So I will just say one additional thing that throughout this, you'll see that there's two main elevators, this one here, which is really the public one, and this one back here that's private.

Did you already say that?

Sorry.

- Oh.

No, that's a great- - Okay, good, good.

- Great clarification.

- 'Cause this one in the back, that's more private, but this allows for that connection where any staff that need to go back and forth, but also if there's a patient that, you know, is mid visit, and someone can escort them down to go get some quick imaging.

So let's say that they have an injury that needs an X-ray, or an MRI, or something like that, that makes 'em go down and do that at the same time or go down and get their labs taken.

So now we're at the second floor.

- Yes, so like I mentioned at the beginning, the second floor is primarily staff.

This is where their offices are, their executive admin, their clinical admin, and their residency admin.

And so a big part from visioning and programming was figuring out how to get these departments all to be together on the same floor, because handoff and communication is huge within just how people can do their jobs.

And so that was really important to them to have that collaboration while maintaining privacy, as well, for their individual tasks.

So that was a big lift on getting that together.

Also on the second floor is a couple more public functions, one being the counseling service.

So thinking about the different counseling and therapy needs that they had, we wanted to lift that up off the main public area just to provide a more discreet and private path for patients that might be coming for counseling services.

This is a smaller community.

It's a smaller micro community, and so that was something that they felt really passionate about just by the nature of where they are.

And so having that right off those public elevators on the second floor doesn't hide them by any means, but it just provides a more dignified path for anybody who might, you know, feel uncomfortable or a little shy about those services.

And so then in the middle of the second floor is their training area.

They have a really strong residency program, and they do a lot of teaching, education for their staff, but then also, they have different events.

And so having that centralized off that main, two-story, double height space really opens up and provides it to be more of a destination and something that could be enjoyed if you're in an all-day conference session or something like that.

We all know how long those days feel when you don't get any daylight, and so this training area opens up onto that double height space, gets in a lot of natural light, and provides that flexibility that they need.

- And I think Hannah really talked about this already, but just to link that back to the guiding principles or the core values of this project, we're really about that elevated presence, and this not only, you know, this helps for the staff joy, this helps with elevated presence, this helps welcome, that allows this to feel, like, uplifting and thinking about being able to sort of have that walk where you see this green space off to your right as you walk and just open to sort of like this gem of the whole site is really amazing.

- Now we're at level three.

- Going up.

No, just kidding.

(laughs) - Yes, and on level three is the first clinic floor.

So level three has four pods of clinics.

Each one has, I think, about 15 exam rooms, and they offer a variety of different clinic types, and most of those differences are on the fourth floor, but having similarities between the different pods was really important for them just for their process and for continuity.

And so you'll see on the south side that light yellow pastel area.

That is this large, shared waiting space.

It opens up to all of the clinics, and the whole south side is all glass.

And so that provides beautiful views out and floods that whole waiting area with natural daylight and even into part of the clinic areas through that green-ish core with where their nursing stations are.

And we'll look at that in a little bit more detail.

But overall, public is on the south side where that yellow bar is, and then more of the staff flow is to the back, and it's in that far back corridor.

And that just allows them easy access to be able able to get to each of the clinics quickly and just traverse throughout this floor.

- And some of the things that I love about this, in addition to all the wonderful things that Hannah just shared, are how this back, where you see these different colors light up, some of them are are traditional leadership, but a lot of them are allied health services, right?

Because they have a model where mental and behavioral health is integrated throughout, as well as sort of wraparound services like helping with lactation for new moms and thinking about all of those processes.

They have people that specialize in that that help, and the mother and the baby can go back there, or they can come up and meet them, and that just like really provides that ease of flow and that integration of care.

And then, I just love, like, not only do they have this beautiful main lounge space, but this exterior space, as well.

And I just think this is such a gift to their staff and to the community, and they are such a gift to that community, honestly.

Can't say enough amazing things about these wonderful people.

- Yes, agreed.

Okay, and then zooming into the typical clinic pod, like I said, they are all very similar.

And if you can kind of see on the left side this key plan, there's this central core that has the check-in, registration, kind of down at the bottom, a shared team space, and then an open team space right there in the core.

And on the north side of this little clinic pod is the resident bullpen.

And so surrounding all of that are their main exam rooms.

And so this allows them quick access between patients, to their charting desks, and to the resident pod.

And so that is duplicated four times on each floor.

And then- - And Hannah's not showing you the amazing, like, physical mockups that we did onsite with them to really, like, test out all different sorts of scenarios.

And it was really wonderful.

Anyway, sorry.

- Yes, that was a lot of fun.

And then, okay, looking inside the room, there was a few primary points that we learned from the mockup and a few things that we had kind of studied.

So one being whenever you first walk in, a privacy swing door.

That was really important with thinking about that patient experience, knowing that they're going to do a variety of types of services in this room.

Having that privacy so the patient is behind the door just really helps give a little bit of confidence that whenever anyone's walking in, you are not exposed.

And then thinking about the communication between the clinician, the patient, and their family.

That was something that was a lesson learned from the clinicians that they were really passionate about improving and wanting to incorporate in this new design.

And so we walked through a few different options on how that could look, and where we landed was having the patient sit right next to the clinician, kind of, that's primarily where the interaction would be taking place, so that they get to know them, they get to talk with them about their medications and all of that introductory stuff, and then even when they move to the exam table, they're still in good communication and sight lines to both their family, and the clinician, and the monitor.

And so thinking about the different locations in the room where the patient might move back and forth, maintaining that visibility and that face-to-face communication was really important.

And so yeah, so we studied how this might look.

And go ahead, Erin.

- No, I would just say, you know, there's a body of research on this topic, on the importance of face-to-face interaction, but also, like, as Hannah said, where there's the ability for us to share screen, right?

To be able to like see the same information so that my chart doesn't feel like a secret to me.

And like, you know, if we gave the presentation like this, right, wouldn't be very much fun.

(Erin laughs) Just kidding.

But I just think, you know, it's really obvious, I think, and intuitive to a lot of us, but it's wonderful to know that there's actually research on basically feeling understood, feeling like you can open and disclose whatever's going on, because you know, you're trying to develop that level of intimacy very quickly between the provider, the patient, and their family member.

And being able to have shared information, shared screen.

One of the reasons that there's a bump out is so that all the people can come around that, but also so that, for instance, if I bring my medications, I can put them on the table and we can sort of open them, talk about them, look at different sheets of paper that may, you know, help me to know how to, maybe I'm getting a new inhaler and that's going to take a certain type of process to help me learn how to use it.

Well, we need a shared surface, we need a shared screen to be able to sort of understand this and work together.

So yeah, it's wonderful.

All right.

Going up the stairs.

- And so moving on up.

(Erin laughs) Yes, on the top floor, one of my favorite parts about this clinic and what they offer is a dental clinic.

I think I love it so much because they literally have some of the best views.

So they're on the fourth floor on the very top and to the right of the plan.

Most of the dental bays, actually all of the dental operatories look out and just gain all of this natural light.

So they have wonderful views.

And I don't like going to the dentist, and I don't know anyone who does.

And just knowing that, like, you could potentially be going to somewhere that is so beautiful and that really values the patient experience, it just, it makes me really excited, (laughs) and I can't wait for it to open and to see, like, what that's like.

So this is an expanding service, because they care for a lot of patients.

And so overall, just thinking about, you know, if they're expanding their services and they're gonna be getting in more patients than they typically have seen just because of the demand, getting to work through them, what that process flow was gonna be and how to maximize the space that they have in this clinic pod was just a real joy.

And so thinking about the whole experience from when you check in and then when you check out, it was really fun.

- All right.

And now we get to shift into the Q&A.

I just wanna say, you know, thinking about those four pieces, right, the community engagement, community and stakeholder engagement, the social determinants of health from a broad standpoint, and thinking about how the built environment and the clinical care can help to be integrated and to support that.

Also, the components of the integrated clinical care team.

And lastly, sort of how this becomes a integrated wellness and health hub for the community.

It's all really central to what makes this a wonderful place.

(upbeat music)