Hamilton Health Care System identified a pressing national healthcare need: the limited availability of behavioral health centers for children. The result was the pursuit of a center of excellence located within its Dalton, Ga., community. With a donor on board, the $18.6 million project moved forward—but under a fast-track schedule of 22 months from site selection to opening. A steep, heavily forested site ultimately inspired a treehouse-themed concept that was quickly approved, and the Anna Shaw Children’s Institute was completed in March.

The 54,000-square-foot facility houses services for patients in need of cognitive, developmental, or psychological treatment, such as physical therapy, occupational therapy, counseling, and behavioral support. To achieve an appropriate sensory experience for the population’s varying needs, the design uses the building’s three floors to represent levels of a forest (floor, understory layer, and canopy) and takes advantage of the sloping site to provide two dedicated entrances—one for patients visiting frequently for therapy and another for those on the autism spectrum or with other behavioral health diagnoses. A hallmark of the concept is a 40-foot whimsical and touchable tree stretching from the first floor to the third (a nod to an existing historic tree on the site).

Jurors loved not only the appropriate aesthetic response to the facility’s patient population, but the level of care that went into establishing an elevated care environment, even without many peer facilities to guide design solutions. Programmatic highlights include patient care rooms that support child-to-caregiver interaction, space for parent education and involvement, and a kid-friendly scale for the center that serves children up to age 11.

The project was submitted to the Design Showcase by ESa (Earl Swensson Associates). Here, Justin Roark, senior design manager at ESa (Nashville, Tenn.) and lead designer on the project, shares his perspective on some of the design elements jurors liked best.

Healthcare Design: The entire project schedule was 22 months, and yet a project of this caliber was achieved. How did you find a way to make it work?

Justin Roark: Early in the conceptual stage of the project, general contractor Brasfield & Gorrie was quickly brought on board with the vision to create something special for the children in the community with a robust project delivery schedule. In collaboration with the design team, we worked backwards from the donor-requested construction start date to determine what early release construction documents would be required to meet the schedule. Our design team worked tirelessly to create packages to deliver to the contractor in a just-in-time delivery manner, to seamlessly meet critical milestones in the construction timeline in a true “fast fast-track” project.

Construction was beginning on the site while we were designing a core and shell building with overall defined program goals. During programming and design, we worked within the box that was established during the core and shell phase to maintain the building footprint and keep the project on schedule, as the construction was well ahead of the interior layout of the project. The project did need some value management to meet budget, but the team prioritized the elements that wouldn’t impact schedule and that could be reduced to meet the owner’s budget.

The integration of the building within the context of the site was applauded by jury members. Tell us how you approached siting the building to use views, slope, etc., to your advantage?

In the first meeting with the owner, before any detailed programming began, we walked the site where leaders wished the building to be located. They selected the site due to proximity to their existing campus but hadn’t verified if it would truly accommodate the program. While walking through the thick wooded area, I envisioned children playing among the trees, and it took me back to my childhood days. I can remember playing in the woods and exploring, creating, and enjoying the nature around me. With the only detailed component of the project established to date that the building would be for special needs children, I thought what better than to let the site itself inspire the building form. And thus, the concept for a modern treehouse in the woods was born.

We knew the scale of a large building wouldn’t fully translate to a typical vision of a treehouse, so we aimed to create a scaled version where one can interpret the vision of the sloped roof line of a treehouse mixed with a modern glass box.

Once we began surveying the site, we found several historic trees that began driving a key focal point to the orientation and view of the building. From that point on, our datum line was set and the building shape, orientation, and internal layout followed suit to highlight the key features of the unique and natural site with solar orientation and views in mind. Another key challenge to the site was the steep slope across, ranging from 40 to 50 feet from the northwest to the southwest side. With such a steep slope, we needed to get creative on how we would locate a 60,000-square-foot building and also maintain an appropriate amount of parking for the building.

We used the grades to create opportunities that would benefit one of the program goals set at the time: dedicated entries for specific patient populations. We lowered the building into the site and created a lower level with a dedicated entry for behavioral health patients on the rear of the building. On the north side (front), we created the main entry for the majority of the traffic coming into the building such as frequent physical therapy appointments and other public functions. This allowed us to enhance the patient experience by creating separate entries into the building for those patients who have high sensitivity to noise and other distractions.

The surrounding natural landscape also inspired the interiors theme/design concept for the building. How did you achieve such a successful result that’s appropriate for this specific patient population?

With the overall design concept of an interpretation of a modern treehouse in the woods, we knew we didn’t want to be literal with the treehouse concept, as it could get overly distracting for the patient population. We wanted to create childlike scale and a place that felt like it was intentionally designed for children yet feels comfortable for the entire family. Through research and input from the director of the institute, Terri Woodruff, we learned that children on the autism spectrum can easily be distracted and upset when faced with bright and dramatic colors, florescent lighting, loud noises, crowds and abstract forms not easily recognizable. We aimed to create a simple balance of color and play, yet not overwhelm the children with busy foreign shapes and colors they wouldn’t be able to process.

One example of a simple recurring shape was the introduction of the idea of the “porthole,” aka a circle. The idea came from a treehouse roof where a branch would poke through the roof in an opening. We used this idea to create lookout windows for children at varying heights and feature areas of the building, skylight openings in the lobby and exterior roof line, and light fixtures in key wayfinding areas of the building such as waiting areas, check-in, and elevator lobbies.

How did you find a successful way to balance the needs of patients experiencing both cognitive and physical challenges when there aren’t many (if any) similar facilities to use as models?

We began researching evidenced-based design solutions around behavioral health design. There isn’t a large amount of research specific to pediatric behavioral health design, so we utilized site tours to understand what other facilities offered with the intent to build on their program and improve upon the lessons they learned. Throughout our tours, we found common challenges of mixing a clinical practice for children who have behavioral disabilities with a calming environment to reduce anxiety and promote healing. We had a key design driver in the process that was continually echoed: “We don’t want a building that looks and feels sterile. We next listened to the patient and family advisory council created by the institute.” We wanted to understand patients’ needs and what would make their lives and clinical experience better.

We took feedback on amenities and programmatic offerings and began brainstorming how to best achieve a calming yet playful environment. We continued to hone in on the simple concept of a treehouse and highlight the levels of the forest. We wanted to use the levels of the forest concept for the interiors to create wayfinding, education, and color variation throughout the building. I believe creating a simple concept and staying true to it without overdoing it was both the biggest challenge and our biggest success of the project.

In terms of the population served, jurors loved the thought put into serving the children as well as their families. How did you approach the process of understanding user needs and delivering an environment that supports them?

Throughout our tours, we found one facility that had the concept of an observation room, but ultimately was not used and was turned into a storage room over time. Terri loved the idea of using such a room to educate the parents of the patients. Throughout our design process and research, we began to understand that autism and other behavioral health diagnosis for children will not be completely cured but managed. And Terri understood that the role of the physicians and clinicians were to diagnose, provide care and guidance, and educate the caregivers of the patients.

Once the child leaves the institute, it’s up to the parents and caregivers to continue to provide care to the patients and work through their disabilities. With an observation room adjacent to the interview rooms (intentionally designed not to look like a typical exam room to reduce children’s anxiety), the parents/caregivers are able to view the treatments without being seen by their child and cause any potential distractions.

This project represents the opportunity that exists to vastly improve behavioral health environments. What did you learn by delivering this project and what do you hope design colleagues around the country take away from this, as well?

I feel our team learned a great deal about how to create an environment that balances a highly sensitive patient population with a calming design solution that enhances the treatment and care within healthcare design. We put ourselves in the shoes of the patients and their families to create a space we would feel comfortable in and actually want to go to. Not often does a child or parent want to go to the doctor, but we’ve heard feedback that children and parents look forward to their next appointment and are excited to ‘go to the treehouse.’ As an healthcare architect, that’s what makes all the challenges and stress worth it; to create a space in which people feel comfortable to play, learn, and get treatment.

Specifically utilizing evidence-based design research around behavioral health design proved beneficial, yet there is still not much out there in the world of behavioral health design for children. We leaned heavily on the expert knowledge of the institute’s director and feedback directly from families in the community. We learned that not all behavioral health is the same. Children are uniquely different than adults and thus their treatment and the built environment in which it is housed it must be unique.

My advice to my design colleagues would be to listen, learn, and grow with their clients. You need to be a part of the journey of creating the building with them and not just for them. You can be the expert in healthcare architecture, but any expert will tell you there is always something to learn. I’d also tell them to be open to new ideas and embrace your inner child. Children like to explore, have space to play, and at times find a quiet place to rest. Use your abilities to create a safe place for them, and they will use their abilities to bring it to life.

One feature you just can’t miss is the tree—the jury loved it. Tell us about the design process and how it was executed.

The design process for the tree was a critical piece to the project. The overall design intent was for a focal point in the building to enhance the levels of the forest by giving true scale to the volume within the 52-foot-high, three-story lobby. The only fitting solution was the bold idea of a tree. We envisioned big ideas for the tree and landed on a tree sculpture to go along with the modern interpretation of the treehouse. We wanted a balance between a literal tree and one that was a modern interpretation of a tree. The project team, along with the owner, interviewed several groups to find the right fit for the design and construction of the tree. Ultimately, Malone Design/Fabrication out of Decatur, Ga., was selected to design and build the tree sculpture.

The design process went through several renditions to refine the look and feel to structural stability and constructability. In coordination with the design team and contractor, Malone created a tree sculpture comprised of two main elements, a base tree structure and a hanging mobile canopy. Factoring in installation and long-term maintenance, the design was finalized using a steel main frame structure wrapped in foam and coated with a resin tree bark-like pattern for the tree trunk and resin panels with custom leaf prints attached to the tree and hung from the ceiling by cables.

As for cleaning, the process will be a combination of a duster attached to a painter’s extension pole and a small air compressor with air nozzle on the end of the extension pole. The top is accessible by the lookout balcony on the third floor or a small scissor lift coming from the first floor. We purposely did not put any lighting directly above the tree as it would be hard to maintain, so we up-lit the tree from multiple points with track spot lighting.

What’s your favorite element of this project and why?

My favorite element of the project? This is a very tough question as there are so many elements that individually are unique, but ultimately come together to make the entire project a whole. From small elements like custom animal wall graphics for each interview room that align with the room signage and artwork within the room to the overall exterior design and building composition.

One of my favorite parts of the building is the approach. From about a half-mile away as you enter on the main road to the building, you pass the main hospital and begin to gradually drive up a hill. As you approach, you can see the building looking right at you through an opening in the trees where the angled glass side of the building is pointing directly at you. This view draws interest in wanting to know what is perched at the top of the hill among the trees. As you enter the main drive from the road, you meander through the woods and come to the top of the hill where a clearing opens up your view to the building.

I was inspired by my toddler’s children’s book called “Life.” In the book there is a section that talks about how in life there is a stretch of wilderness now and then, but the wilderness eventually ends and there will be a new road to take. This is a “wow” moment symbolizing a journey through the woods only to come out the other end with inspiration and a hope for a better future. We wanted to not only create an experience within the building, but an experience upon approach to the building by enhancing sense of nature and arrival.

Jennifer Kovacs Silvis is editor-in-chief of Healthcare Design. She can be reached at jennifer.silvis@emeraldexpo.com