Well, Howdy Welcome to Friday Architecture for Health Lecture Series Our guest speaker today is Tim Rommel, a mental health care practice leader from Cannon Design.

Tim has been a health care architect for over 40 years, with nearly 35 years of experience focused on behavioral health care facilities.

And he's leading the Cannon designs behavioral health care studio.

He's a recognized expert in the planning and design of psychiatric care facilities with several dozen highly regarded projects, to his credit.

He has shared his understanding of the unique issues and concerns of behavioral health care facilities and articles, presentations and lectures at a number of international and national conferences to date.

And today, he has joined us on Texas A&M campus.

So please let me welcome Tim Romo to the podium.

Thank you.

Thank you.

Thank you for being here.

As Roxanna said, I'm Tim Romo.

It's an honor and a pleasure.

Pleasure to be back here at AA and my alma mater.

I'm very proud, Aggie, this year lecture series is going to focus on mental and behavioral health, and I'm honored to be the first one in that series of very prestigious individuals that will be talking about mental and behavioral health design aspects.

So what I thought I would do is start off with three things.

One, some general comments about mental and behavioral health.

Two types of mental and behavioral health facilities.

And then three, a little bit deeper dive into the acute care, mental behavioral health facilities and the types of facilities that exist.

I'd like to start with talking about mental health by the numbers.

Mental health is an important part of our entire health care system and health care well-being.

Most people don't understand the impact that it has upwards of 25% or greater of our population will suffer at some point in their lives.

A serious mental illness.

That's one in four out of all of the population.

And the impact is not just the patient but those around them.

Serious mental mentally ill patients have a 25 year less life expectancy.

Now, think about that for a minute.

The average life expectancy in round numbers for an adult male is about 75.

It's gone up a little bit more.

But for round numbers, 75 take 25 years off of that.

That means someone with a serious mental illness has a life expectancy of only making it to 50 or less.

The economic impact of mental illness is huge if you measure it in GDP, gross domestic product of this nation or any nation of the world, it far outweigh those the next five physical ailments in health care.

And that includes things like cancer, cardiovascular disease.

All of the top five added together, mental illness has a greater impact.

Suicide rates for adolescents and young adults is the second leading cause of death.

That's a huge impact.

When we talk about what is the size of mental health care in terms of beds within our systems, we have about 39 mental health beds per 100,000 population.

If you compare that to acute care or health care, that's about 240 beds per 100,000 population.

So you can see there's a huge disparity between need and resources available.

The tide is shifting.

It's always changing.

Mental health care was really first addressed at a national level back in 1965, when through most of the country and states we had very large mental health facilities, state run hospitals.

Some of those hospitals had five, six, eight, 10,000 patients in one place.

Now, I'm not saying that was the right answer, but at one point that was our system in 1965, started by President Kennedy and then enacted by President Johnson.

It was to remove a vast majority of funding for those inpatient beds and transfer that funding to community based behavioral health or mental health care systems.

Every patient did not need to be in a mental institution.

The first part of that happened were do the number of beds.

The second part of that never happened.

There was no funding for those community programs.

And hence today you see out on just about any street in America the results of that in terms of homelessness and individuals afflicted.

In 1996, mental health parity came into play and it was a ten year implementation fully implemented and 20 to 2006.

That means that health insurance coverage could not discriminate against mental health care in the past.

Mental health care and insurance probably with this policy, would say, I'll cover an individual up to $2 million for cardiovascular disease or cancer or so on.

Mental health care had a very small comparative funding in that mental health parity fund.

Insurance companies, you cannot do that anymore if you offer $2 million in coverage on this.

You need to offer $2 million in coverage on mental health care.

More money into the system.

Also very close to that, the Affordable Care Act, Obamacare, which brought in a bunch of people having health insurance that never had health insurance.

And then we add in 20 years of war, starting in 2001, after the World Trade Center tragedy, the impact that that has had on not only the veterans who served, but also the families that were here or the families that were left behind.

Huge impact.

Now, one of the interesting facts is one of the leading afflictions of that is post-traumatic stress disorder.

Post-Traumatic stress disorder can happen immediately after an event.

Typically, it's 5 to 7 years out after an event has happened.

So we still have not hit the peak of that tidal wave of need.

And then obviously, social attitudes, stigma and press coverage.

There's not a day that goes by that you can't look in a newspaper or hear on the news.

Some tragic event which was precipitated by some mental illness aspect.

And, you know, there's examples close to here not involve the incident.

Just a little while ago here in Texas.

What is the difference between a physical inpatient care and acute care?

Inpatient care?

Well, if you think about it, a person with a physical affliction, a heart attack or so on, they spend 85% of their time when they're in the hospital, in a bed, in a patient room, in mental health care.

That's the last place that you want that patient.

You do not want them in their bedroom.

You want them out receiving care in an active environment.

Primary concerns in physical medicine.

Infection control.

Just the changes in my career that I've seen in terms of hand-washing stations, placement of hand-washing stations, hand-washing stations and patient rooms and so on in mental and behavioral health care.

There's a different primary concern and it's patient safety and how that is going to be handled and in the environment.

Right.

The difference between the spaces on an inpatient unit in a mental health facility because the patient is not in their bedroom, you want a variety of spacious variety of spaces.

Some are very active spaces.

Several patients and staff members can get together.

It may even be a ping pong game going on or a television watching.

Some are much more quiet and subdued because patients have different needs.

Not always at the same time.

And it changes across their treatment while they're in there.

The average length of stay between the two populations in mental and behavioral health, we're talking about days typically five to 7 to 10 days on the lower side and in some cases up two years.

In acute care medicine, we're really down to a couple of days, if not just hours, in an inpatient unit.

So let's talk about the spectrum of mental health illness.

There's probably twice as many different types of things that fall under mental health, the spectrum of mental health.

I'm going to focus a little bit on mental health, behavioral health, acute care environments, and we'll talk a little bit about that.

But there are others addictions disorders.

You know, the impact that whether it's alcohol or drugs or so on as have into our society, eating disorders and other disorders, dementia and Alzheimer's.

Just the past 20 years, the growth and understanding of that affliction and especially facilities that are needed to address that TBI or traumatic brain injury and that can be anything from sports related in injuries, accidents, incidents coming out of the war that we've just been through and are still happening.

IED facilities, individuals that have been born with diminished mental capability and need care and need care throughout their life.

And then finally, autism spectrum.

And this is another area that's really changing over what's happening and how it's happening and great advancements being made.

And as I said, there's probably twice as many more subsets that can fall within this.

But this is what we the the main areas when we talk about mental and behavioral health care facilities.

Now, I'm going to talk about acute.

So let's take a little look at that.

So we see kind of six main areas.

Once again, there's probably twice as many.

The first being the acute inpatient environment.

We'll talk a little bit about that and some of the special aspects of that.

The second mental health recovery centers.

Supportive transitional housing.

So this is kind of step down from that acute inpatient environment.

P IAP and Day hospitals, partial hospitalization program intensive observation program, and then day hospitals.

Those are areas where patients do not spend the day or excuse me, do not spend the night in the hospital.

Outpatient clinics, special mental health, outpatient environments and now telehealth.

And one of the interesting aspects about the COVID epidemic is the proliferation of telemedicine for behavior or health.

Another interesting fact it would not be covered at the same rate as physical telemedicine up until COVID.

Now a doctor who performs telemedicine gets reimbursed at the same rate as if it was a personal visit.

The financing has a huge impact on our system.

So the acute mental health inpatient unit and I'm going to use mental health and behavioral health interchangeably, there is a clear definition between them, but mental and behavioral health for this purpose is going to be the same.

Each community, organization or environment have different needs.

Different inpatient units or hospitals may have different purposes within the system, and those need to be addressed.

Solutions are not one size fits all.

There are state facilities and states have a certain purpose within the mental health care delivery system, and each state is different.

The average length of stay within the acute unit often short, but in many cases, depending on, as I said earlier, the facilities they can be long term stays with them.

So we focus on the patient experience, dignity and safety.

Every one of the facilities needs to be absolutely safe.

When a patient is in crisis and begins to act out, they need to be safe.

We need to provide a safe environment for them and those around them.

But it must be dignified.

It cannot be overtly safe.

Our best environments that we want to create.

You don't know how safe they are.

They look as normal as could be.

Those environments can manifest themselves in a number of different configuration.

There is not one single config operation that fits all of the needs.

And so as designers, we need to be looking across the spectrum of opportunity within this design realm.

And that's really where a lot of creativity comes to play.

OC Mental Health recovery Centers Supportive and transitional housing.

I'm going to show you a project example and I put down here I am exclusion.

That's a special federal regulation that says you cannot use federal dollars for inpatient mental health care and a freestanding hospital if it has more than 16 beds in it.

Those are adult hospitals.

So from 21 to 64, federal dollars cannot be expended.

Medicare, Medicaid dollars cannot be expanded on these type of facilities.

Does it mean that people between 21 and 65 don't need mental health care?

Well, you bet they do.

So there are some creative ways that have been looked at on how to get around it.

This is Cordillera Hospital in San Mateo County and California.

What you're seeing is the existing facility was a 1960s hospital that needed to be replaced.

The outcome because of that IMD exclusion.

They wanted 64 beds.

We designed the hospital that is actually four independently licensed, 16 beds that sit within feet of each other so that they could capitalize on the reimbursement.

So things that we have to do are not always driven by the FDA guidelines, medical practice.

There are other aspects that come into play in what we do as designers here.

It's financial and federal regulations that is driving a design.

Now, this facility up in the right hand side here is a transitional housing facility.

The purpose of that is as patients move from the in-patient environment, the most acute level of care, stepping down to transitional housing.

A number of those patients are going to regress in their progress and have to come back into the inpatient environment.

Another will do well and be able to move off campus or back to their homes from this.

So that transitional piece is an important piece to keep the acute care system working.

If you don't, you can get backed up really quickly.

And that's an image of that transitional facility, basically small apartments for the patients as they move out of the inpatient environment, partial hospitalization program and intensive observation programs and day hospitals.

So partial hospitalization programs, if you think about it, it is a program.

All of the things that happen on an inpatient unit with a patient, it just doesn't have the beds.

So patients in and P will live in their home or reside in their home in the morning.

They come to the hospital and they spend their entire day receiving the same treatment that they would have received in the inpatient environment When it's into the evening, they go home.

So it's a level below that transitional housing.

IAP programs are similar, less intense.

So a patient, if it's an adolescent, for example, may be at school during the day after school.

They come to the IAP program, spend that time and at night, then go home.

So it's really a gradation of different in environments and care levels for those afflicted with mental illness.

Okay, something came up here.

Hold on.

Okay.

And this is these are some examples, you know, in the other.

This is a typical IAP or P small program that's been depicted.

This is Sheppard Pratt Hospital just outside of Baltimore, a newer facility and one of the programs.

This is the entire complement for that particular hospital.

Of the three programs, the clinics, the IAP and the P, the one on the right happens to be an eating disorder clinic.

So it has some very specialized spaces within that for cooking, eating, training, those kind of programs, crisis stabilization units, mental health, behavioral health, emergency departments or sections within emergency departments.

And I know you're going to hear a much deeper dive into this type of facility here in the coming weeks.

If you think about an emergency department, typical emergency department has everything from major trauma, heart attacks, broken arms, broken bones, wounds, just medical sickness going on.

There's a lot of machines in there, a lot of beeps, a lot of sounds, a lot of activity of staff and so on.

Working on patients, a mental and behavioral health patient coming into that.

That's kind of the worst environment that you want them in that very active environment, stuck in a room with no windows, lots of stuff around, lots of stuff going on.

Unfortunately, with our system stays in an emergency department for a mental behavioral health patient can be 24 hours or more up to days and weeks in that waiting for a bed in a different environment.

So that's kind of the reason for crisis stabilization units.

It's there's been tweaks on that name, but it's kind of the same thing.

Create an environment that's focused on mental and behavioral health care and how that is going to be treated within.

And it's typically in an emergency department have to go through triage once a determination is made that, you know, this individual needs mental and behavioral health care, that they're medically stable.

You know, they have their own tracked within that.

And what do these departments look at?

They're much less intense in terms of medical equipment, much more social in terms of their environment.

We utilize the living room concept.

So if you think about a living room, things that happen within a living room and the idea, the interaction between patient and staff and patient and patient little clusters, we may have patients here for 24 hours.

So using recliner chairs so that they can take and sleep a little easier and those kind of things, some private spaces within that as well.

And so once again, different environments, safe, dignified for the patients and then outpatient clinics and telemetry, telemedicine, I'm sorry, outpatient clinics, if we look at it, they can be a dedicated mental health clinic or it could be part of a much larger system where it's just another clinic or even further it's a patient in a treatment space, and they may receive physical medicine consultation or they may receive mental health consultation.

It's the same space.

And so there's a number of examples.

The one on the left is a mental health clinic for the military at Fort Liberty and North Carolina.

And this is a facility up in Canada outside of Toronto.

And then finally, specialized environments within mental health care.

You know, we kind of focused on the pure mental health.

55% of mental health patients have some co-occurring disorder that they're afflicted with.

So we need to take and look at some of these specialized environment.

Children and adolescent have different needs than a 64 year old gentleman.

Co-morbid facilities where you're treating both mental illness and physical illness at the same time.

Geriatric many mental health facilities.

And then finally, forensic.

And there are as many more listed as these so quickly as we start to wrap up children's mental health or child and adolescent facilities, creating environments that are impactful for children and so on.

Once again, all the same aspects that we look for in all of our mental health facilities.

But really at a child and adolescent scale.

Okay, let's look at some of the comorbid spaces.

Are there spaces that we can create that can help treat both physical and mental illness at the same time?

A number of our health care organizers nations have been focused on creating that universal room that provides that opportunity for the treatment of co-morbid patients and spaces that are safe when the mental health takes priority, but also has all of the services available for that physical medicine, medical care.

Okay.

Questions?

Yes, ma'am.

so when looking into adolescent or child mental health, what are good resources in order to, like, analyze if we're doing a project in that sense, like aspects that we really want to focus on in order to achieve giving them the best design possible?

Yeah.

So if you if you think about a child or an adolescent, the choices that they're going to want to make are going to be different than an adult.

And there is a picture of a child kind of cuddled up in a little almost sphere in the wall, you know, that that warm embrace that that we can help create in that environment is important.

And, you know, it's focusing on that.

And if you think about a child mental health facility is going to treat individuals from three years old up to about 12, there's a big difference of what interest and, you know, what brings pleasure to different age groups within that.

And then the same for adolescent from, you know, that 12 to 18 years old, you know, when I was 12, I was probably more mature than I was when I was a teen.

So, you know, it's creating those different environments that are flexible enough for the appropriate disorder.

So in Canon Design's approach, a process, is there a period where you would interview the actual patients or the users of the space?

And if so, can you tell us what that looks like?

Yeah, so we do try and on projects, interact with the ultimate user or the patients and utilizing much of that input in our designs.

And I remember a few years back we did a new state hospital for Arizona, Arizona State Hospital in Phenix.

We interviewed a number of patients and they were long term patients that were going to be there.

And I remember one gentleman where we had a very long conversation over an afternoon.

I went back to that facility about two years after it was open, and that same gentleman was there and he came up, grabbed my hand and shook my hand, and he said, Tim, you helped me.

He said, you made it safe for me, safe from other patients, but most importantly, safe from myself so I can focus on my healing.

And, you know, that's part of why we do what we do.

So thank you.

Yes, ma'am.

I noticed that many of the floor plans of your show for the facilities typically had the nurses station center.

All the patients?

Yeah.

Effective.

And yeah, that's.

That is a big point of discussion right now.

The very first slide I had up there when I showed the inpatient, there was just kind of a table and some cube chairs and those kind of things.

That whole space with those chairs and cubes.

And so that was a nurse's station.

That institution decided we're not going to have a counters between us and the patients.

We're going to take and be within the milieu of care providing, you know, those essential functions.

There are areas outside of the milieu, you know, where important things need to happen, dictation and so on.

But it doesn't have to be the glassed in fishbowl, you know, the nurses station with the glass all the way around it.

It doesn't have to be that big wide counter.

There are instances that those are appropriate, but there's also instances where you don't need to be in the MOU, and that's every project we've done.

That is a big discussion point.

Yes, sir.

So you use kind of talk to form the same question you mentioned about safety, and it was, I believe that for the input or were you up there to say that they will be safe, but they will never actually know how safe it is?

Yeah.

So how do you like I mean, that would be like providing them safety for the care givers and also the patients, but like, respecting their privacy.

Right.

They'll never know, I mean, how safe it is.

But at the same time.

Yeah, the dignity as you said it.

Yeah, absolutely.

And, you know, as simple as something you don't think about the corner and a wall where it comes together, you know, there's a metal corner bead that runs down in the drywall and it gets, you know, spackle in and so on.

But it creates this beautiful, nice, sharp corner.

But it's a sharp corner.

And so if I want to injure myself or injure a staff person, I can bang my head on that corner and I'm going to cut my head open, you know, pretty easily.

And anybody that has had little kids, they've seen that happen, you know, kids running around bang into the corner.

And I got a little bang there.

So so we use is a bolanos corner.

Around the corner.

So if someone does, you know, is in need and they act out and they want to bang their head on that corner, it's not going to be as damaging physically to them.

And so that's where, you know, it's kind of a dignified safety element.

Someone walks into that room, they'd never see that they would never know the difference.

But it's safer than, you know, the first one and all kinds of elements like that.

The walls that we use in patient care, bedrooms all have plywood behind the drywall so that if a patient wants to act out, you know, if they're behind a door, the doors close, they can start breaking up that room.

You know, they can start punching through those walls.

They can start kicking through those walls.

And that creates a whole bunch of other danger items.

So by adding plywood behind the wall creates a durable backing that they can't get into the areas that are of concern and create even more threat to that patient.

So it's those kind of things, things that you never see, man, in terms of evidence based design for different obviously different health care products, do you have a certain standard that the firm follows or do you do more project specific research?

So if I understand your question and I apologize for do we have standards that we follow, is that I'm more saying like, do you use like basic standards for all of your products or for some of them?

Do you go into more like product specific design research things?

Yeah.

So both, you know, there's federal guidelines and organizations that have things in each state.

Some adopt them, some don't.

We follow all of that.

We also look at best practice.

You know what what's best practice, whether it's required or not, we have standards within my organization and I would guess most other big organizations and how we're going to address issues to reduce risk.

And then our clients, many have their own standards.

For example, the Federal Veterans Administration, who maintains a lot of mental health facilities, they have their standards, many of which Canon Design wrote for the Veterans Administration or a larger health system, have their standards.

We take and look at all of those and make sure that we're utilizing using, you know, the ones that are at the top.

Organizations may have a standard for something that creates a risk within a mental health environment.

And so we have to point that out to that client and say, here's the risk, here's what could happen.

You know, and then it's an informed decision that they would have to make.

Yep, just me.

So for the, for are there any classes that the future architects that you would suggest they take outside of the, the curriculum that would better prepare them for the industry?

So if I understand classes that architects take focused on mental and behavioral health research.

Yeah.

So there are a number of health care organized stations, health care design, for example.

different organizations do have tracks within health, mental and behavioral health.

They're constantly offering webinars throughout the year.

Some are full day workshops, some are just hour and absolute monthly.

And it's it's a an environment where we're all trying to share, you know, what each one of us individually has learned, and it's it's important.

Absolutely.

So, yeah, next week I'm going to second announcements.

So we're going to have a great because some.

Yeah, so he's going to be speaking to us about, trying to convince you so we can all.

And so if you guys follow me, then you're going to see, as well.

So thank you so much.

Time again.

Yeah.

Thank you.

Thank you.

All.