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Featured Article:

Rural Healthcare Facilities Driving Industry Innovation

By Amy Douma, AIA, LEED AP


CentraCare Long Prairie - © Corey Gaffer

When you hear the phrase “innovative healthcare facility,” what image comes to mind? A large urban campus with the latest high-tech equipment? A research-focused academic medical center fostering the next medical breakthrough? While there is no question that such facilities are the sites of many healthcare advancements, we have found that rural facilities can also be fertile ground for innovative, industry-leading ideas.

Why is this? As many rural healthcare providers can attest, rural care presents unique challenges. In addition to the evolving care and reimbursement models that are reshaping the healthcare landscape, rural providers frequently face severe shortages in both funding and staff; this adversity engenders out-of-the-box solutions and cultivates a spirit of collaboration and creative problem-solving. As a result, we are finding that many innovative operational and design approaches are being developed by rural health systems.

Rural Healthcare Challenges: An Overview

According to Danielle Gearhart, CEO of Gundersen St. Joseph’s Hospital in Hillsboro, Wisconsin, rural healthcare is not for the faint of heart. As she noted during a joint presentation with HGA at the Healthcare Facilities Symposium and Expo in Austin, Texas, rural providers face numerous challenges, include the following:

Access—Approximately 60 million people live in rural or frontier areas; despite comprising only 16 percent of the population, rural Americans inhabit 95 percent of the total U.S. land area. This creates challenges with access and transportation, particularly given the aging population and prevalence of chronic conditions in many rural areas. Rural patients often travel twice as far as urban residents to the closest hospital in an emergency; as a result, 60 percent of trauma deaths occur in rural America. (2)

Workforce Shortages—Of the 2,050 rural U.S. counties, 77 percent are designated as Health Professional Shortage Areas (HPSAs). Only 11 percent of physicians practice in rural America, and—according to the U.S. Department of Health & Human Services—more than 8,400 additional primary care providers are needed to serve these areas. Unfortunately, the problem is unlikely to be resolved soon; nearly 30 percent of rural primary care practitioners are at or nearing retirement age, while younger practitioners (under age 40) account for only 20 percent of the workforce. (1)

Financial Struggles—The financial challenges of rural healthcare systems are pervasive and growing. Approximately 44 percent of rural hospitals operate at a loss, and 30 percent operate below a -3 percent margin. In addition, rural hospitals have absorbed a combined $318 million in cuts under sequestration, resulting in a loss of 7,129 community healthcare jobs and a $769 million loss to GDP. (2)

Rural providers looking to upgrade their facilities face additional challenges. Construction costs for rural healthcare facilities may be inflated due to a lack of local healthcare expertise among contractors, exacerbating funding shortfalls. In addition, “right-sizing” facilities is notoriously difficult due to highly variable patient volumes and changing demographics. Tight budgets do not accommodate “extra” space, so rural facilities must find creative ways to adapt to change.

Rural Innovators

In response to these unique challenges, many of our clients in rural areas have implemented innovative design strategies that leverage space, staff and technology in unique ways to control costs while planning for an “unknown” future. Several inspiring examples of innovative thinking are described below.

CentraCare Health CentraCare Long Prairie - © Corey Gaffer

Beginning in 2013, CentraCare in central Minnesota and HGA embarked on a comprehensive master plan of five Critical Access Hospitals in five communities surrounding its main regional medical center in St. Cloud. This effort assessed inpatient and outpatient volume trends, as well as potential interrelationships between the five communities and the main hub to address the needs of individual communities while leveraging system-wide resources.

Two recently opened facilities resulting from this master planning study incorporate unique strategies to address volume variability while minimizing space and cost. Both the Long Prairie replacement campus and the Melrose campus addition incorporate a universal care platform—a group of flexible rooms that can serve multiple departments—to serve surgery, emergency, observation and imaging functions. For example, a room that may act as a surgery prep/recovery space in the morning can seamlessly transition to an emergency department treatment room in the evening when those volumes increase. These same rooms can support imaging prep and observation functions as needed.

Through this approach, the Long Prairie facility alone saved nearly $1,000,000 in construction costs and shaved more than 2,500 square feet from the initial building program. In addition, the universal care platform concept will serve CentraCare well into the future. The same flexibility that accommodates daily volume changes will support long-term changes in service lines with very little renovation or expense. This is a great example of innovative thinking that enables high-quality care while controlling both initial and long-term costs, ensuring the future viability of healthcare services within the Long Prairie and Melrose communities.

Samaritan Health Services

Samaritan Health - Image HGA

On another rural campus in coastal Oregon, Samaritan Health Services is working with Skanska USA and HGA to construct a replacement Critical Access Hospital in Lincoln City that will streamline workflow and rethink traditional operational models.

A popular resort community, Lincoln City’s population swells during the summer months—and its emergency department volumes follow suit. Due to this volume unpredictability and a stringent budget, a universal care platform would be an ideal fit for this facility. However, Oregon codes prohibit sharing of surgery prep/recovery rooms with other departments, so the team proposed some unique space-sharing ideas.

The final solution positions several daytime-focused functions adjacent to the ED so that it can expand into these spaces during the busy summer evenings. The first ED “expansion zone” consists of Outpatient Services, a collection of flexible spaces used for lab draws, pre-surgical consults and similar functions during the day. The spaces are equipped as ED spaces to seamlessly change function as needed. When additional ED space is needed, several small imaging spaces (housing ultrasound and bone density testing during the day) can be converted to ED treatment space. All spaces share two entries, creating a cohesive on-stage/off-stage ED unit when in full use.

Should Samaritan’s long-term needs change dramatically, this same unit can easily convert to an on-stage/off-stage clinic module as community needs and care practices evolve. This creative space-sharing strategy expands traditional notions of flexibility and adaptability, ensuring that Samaritan’s investment of today will support future demands.

Gundersen Health System

Gundersen Health Image HGA

Knowing that their new 65,000 square-foot replacement hospital would need to position them for the future, the leadership of Gundersen St. Joseph's in Hillsboro, Wisconsin, teamed with HGA to conduct a deep analysis of service lines and processes. Adaptability and flexibility quickly emerged as overriding themes for the new facility. Almost every space is positioned to adapt to change; each room is designed to maximize every square inch, with no space ever sitting idle.

For example, the inpatient unit and the emergency department are co-located so the ED can overflow into patient rooms if needed, eliminating the need to “oversize” the ED for high-volume conditions. This proximity also promotes staffing efficiency, a consistent concern for rural facilities given their frequent workforce shortages. By co-locating the work areas of the ED and inpatient unit—and by cross-training staff to work across disciplines—Gundersen projects an annual operational savings of approximately $500,000 over a traditional departmental layout. Other examples of space flexibility include a large inpatient room that will double as the infusion clinic and standardized clinic exam rooms, with equipment selected to accommodate most of the specialists’ needs.

Technology is also an important component of Gundersen’s vision for rural care. Leadership has begun exploring telemedicine for services throughout the building, including the ED, inpatient unit, and specialty clinic. Their new hospital’s check-in system is also designed to leverage technology. Check-in desks will be convertible to digital kiosks and can even support concierge-style tablet check-in in the future.

Looking Forward

As rural healthcare organizations explore ways to maximize resources and implement new delivery concepts, they will continue to uncover innovative approaches to healthcare design and delivery. From universal platforms that shape-shift as needs change, to hospitals designed for outpatient conversion, these projects showcase the creativity and dedication of rural providers in overcoming difficult challenges. In addition, they illustrate some unique approaches to care delivery that could inspire healthcare systems of all scales and locations.

About the Author

Amy Douma presented “Rural Healthcare Facilities as Innovation Incubators” with HGA colleague Kiki Werkheiser, and Danielle Gearhart, FACHE, of Gundersen St. Joseph's Hospital, at Healthcare Facilities Symposium & Expo, October 2018.


1. National Conference of State Legislatures.

2. National Rural Health Association.

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