Designing for Integrated Behavioral Healthcare in Rural Clinics

In rural communities, a health clinic is often more than a primary medical care office but a mixture of holistic healthcare services co-located in a single facility. Maintaining separate medical, dental, behavioral health, and other specialty service facilities is not feasible for many small communities due to staffing and funding shortages. Unfortunately, many rural communities lack access to specialty services, with the nearest specialty care facility requiring hours of drive time. Stemming from a lack of access to specialty care and research highlighting increased mental health issues in rural areas, the last decade has seen a rise in intentionally integrating behavioral health services in rural Oregon health clinics.

According to the Families, Systems, & Health journal, “Overall, integrated behavioral health services have been shown to successfully enhance health care services and yield improvements in medical and behavioral health conditions” (Selby-Nelson, Emily M., et al., 2018).

However, due to sociological, economic, and geographic differences, integrated care clinics in rural communities have requirements that may not be considered in urban areas. That is, urban healthcare design experience does not directly translate to rural, and as design teams venture into rural areas, each community’s unique needs must be studied. With over three decades of healthcare experience in rural Oregon, the Pinnacle team is adept at designing integrated care clinics, many of which combine primary medical practice with behavioral healthcare.

Rural Behavioral Healthcare Needs

Although behavioral health services are in similar demand in urban and rural areas, studies show that folks living in rural communities are less likely to receive behavioral health care (Gale et al., 2019). At the core of our mission, we believe that residents of rural Oregon should have access to the same scale of services as their urban counterparts. Rural residents’ barriers to accessing behavioral healthcare can be categorized into availability, accessibility, and acceptability (Selby-Nelson, Emily M., et al., 2018). After working with rural healthcare providers on over two dozen medical and behavioral healthcare projects, our team has learned how to address each of these access issues in design.

Elements of Success

Availability. Maintaining behavioral health staff is an onerous task, especially in rural Oregon (U.S. Department of Health and Human Services, 2021). Therefore, it is vital to develop environments that support staff by preventing secondary traumatic stress and creating sustainable working environments, making recruiting and retaining staff easier.
Pinnacle implements this idea in design by considering the function of a behavioral health space equal to staff and patients. Instead of getting the ‘leftover’ space, our team works with the staff to listen to their needs and plan their spaces with design principles that integrate features that support their work and workstations. Our team has learned to incorporate these needs in the following ways:

Accessible outdoor space
Increased natural light
Incorporated Biophilic design
Flexible space to evolve or adapt over time
Varying levels of acoustical control
Discernible aesthetic differences between staff and patient spaces that create a separation between work and respite
Access to areas that allow for physical activity (i.e., Yoga, meditation, walking paths)

Accessibility. Burdens related to accessibility can include social, financial, geographical, and physical barriers. Considering accessibility early in the design process during site deliberation can help patients overcome some of these hurdles. Site selection must consider proximity to public transportation, housing, and existing essential facilities (i.e., post office, grocery store), and site conditions related to the various modes of transportation. For example, a large slope from the street entrance can make it difficult for folks to walk or bike onto the site. Additionally, with many rural Oregon climates experiencing extreme temperature variations from summer to winter, it is important to ensure pathways are accessible year-round – protected from snow and rain.

Acceptability. The stigma of behavioral health services and the decreased anonymity in small, rural communities decrease the likelihood of services being sought at specialty clinics (Gale et al., 2019). Designing a single access point and check-in lobby for all services provides the patient with anonymity. If a patient does not want other community members to know about their behavioral healthcare services, there is much more anonymity in going to the general healthcare clinic reception check-in than a behavioral health center or separate entrance. In small communities, it is common for people to consider who can see their car parked in the parking lot – word travels much faster in these communities, and the sociological stigma surrounding behavioral health services is more pertinent and likely to deter necessary care. Although having a single check-in for all services can help overcome the burden of acceptability while providing an efficient layout and reducing the staff required for each service, it can also create confusion as patients navigate the clinic. Wayfinding is more than labeling space with clear signage – rather designs can support wayfinding by providing color or artwork to help identify locations and assist patients and staff in navigating space.

These challenges are complex, but Pinnacle has found success using the best practices outlined above. Many of the design standards are evidence-based, leveraging the Evidence-Based Design Accreditation and Certification from The Center of Health Design held by Briana Manfrass. Some of these best practices have been developed as ‘lessons learned’, as our team continues to work with various rural healthcare clients, maintaining open lines of communication and creating positive feedback loops during and after a project.

Best Practices in Action

Hearts for Health Integrated Care Center. Completed last year, the Hearts for Health Integrated Care Center in Enterprise, Oregon, offers a progressive, community-based program focused on integrating physical and mental health to enrich the lives of Wallowa County residents. The program is a highly collaborative partnership between the Wallowa Valley Center for Wellness and Winding Waters Medical Clinic that combines medical, behavioral health, pharmacy, dental, and child development services. This project is unique due to the flexible spaces provided for the greater community, including a teaching kitchen, resource library, and conference center. Pinnacle heard the client’s goals to develop a space to support their forward-thinking approaches to rural wellness – a place to promote the whole health of the community. Learn more here.

Hearts for Health Integrated Care Center Child Therapy Observation Room

Hearts for Health Integrated Care Center Behavioral Health Room

Hearts for Health Integrated Care Center Lobby with Single Check-in Desk

Elgin Family Health Clinic. Located in the small rural town of Elgin, Oregon, the Elgin Family Health Clinic combines medical, dental, physical therapy, behavioral health, and pharmacy services under one roof, and serves between 12 and 15 thousand patients per year. Before the much-needed expansive facility opened, the clinic operated out of a house – a small space lacking privacy. The new, larger facility is a commercial space that uses one large waiting room for all services, offering patients privacy and anonymity. Learn more here.

Elgin Family Health Clinic Lobby

Elgin Family Health Clinic Gym

Elgin Family Health Clinic Behavioral Health Room

Rural community healthcare providers have a smaller pool of resources to leverage when developing or expanding services provided to the community. Staying true to our mission of enhancing lives and communities, the Pinnacle team continues to bolster the efforts of these rural healthcare initiatives by listening to the needs of the community and applying the best practices learned through our experience and research. If you want to talk about a project in your community, reach out to our healthcare design expert Briana Mafrass, EDAC at briana@parch.biz.

Briana Manfrass is an associate principal and interior designer with Pinnacle Architecture. Briana earned an Evidence-Based Design Accreditation and Certification (EDAC) from The Center for Health Design whose mission is to transform healthcare environments through design research, education, and advocacy. Briana can be reached at Briana@parch.biz or 541.388.9897 x22