Marie Henson (Image courtesy: Perkins&Will)
Author’s note: Robin Guenther, a renowned healthcare architect and co-author of “Sustainable Healthcare Architecture” with Gail Vittori, died of cancer in May 2023. As a participant in a clinical trial, she was required to stay at a hospital for weeks at a time, and she ultimately spent her final days there.
In conversations I had with her before her passing, Robin expressed a desire for more thoughtfully designed spaces to accommodate the extended stays that are becoming more common for cancer patients.
In my new role as firmwide health practice leader at Perkins&Will, I wish to honor Robin’s life, legacy, and last wishes. Writing this article is one way to do that.
Evolving approaches to cancer treatment
As cancer care evolves, design professionals have a responsibility to create innovative environments that keep pace with new healthcare approaches.
Patients who don’t require inpatient care—like those who have undergone surgery, radiation, or experimental therapies—still need complex care. This can include 23-hour hospital stays or hospital-at-home services, or they need to remain close to the hospital for recovery and follow-up.
In countries with universal healthcare, such as Germany and Switzerland, specialized cancer centers accommodate weeks-long or even months-long treatment and recovery.
But in the U.S., providing care becomes a balancing act between patients’ treatment and recovery needs and payers’ concerns.
New thinking needed in cancer care environments
The cancer care community is recognizing the problem. For instance, The University of Texas MD Anderson Cancer Center in Houston has identified the need for rooms designed for less-complicated overnight stays.
“People are accustomed to exam rooms, operating rooms, and inpatient rooms,” says Kent Postma, vice president of ambulatory operations at MD Anderson. “We need to find something different.”
Sara Jo Grethlein, chief medical officer for the Clinical Institutes, Puget Sound, and executive medical director at Swedish Cancer Institute, agrees. She adds that new therapies—such as novel immunotherapy treatments—will also drive the need for a paradigm shift in accommodating cancer patients.
“The CAR T [chimeric antigen receptor T-cell therapy] approach is only being used for blood cancers and hematologic malignancies right now,” she says, referring to personalized immunotherapy using engineered white blood cells to target cancer cells.
“As that becomes more common in the treatment of solid tumors, the volume of patients we’ll be treating that way is going to increase. To meet this level of support, we’ll need more and better space to care for patients for longer periods of time.”
Impact of reimbursements, codes on cancer care design
Design considerations for innovative cancer facilities, including their location in or near hospital complexes, are impacted by the complexities of the U.S. healthcare system.
The first consideration is patients’ length of stay. Under the “Two-Midnight” rule, a Centers for Medicare & Medicaid Services (CMS) policy that affects hospital admissions and reimbursements, a hospital stay is considered an inpatient admission and is eligible for Medicare Part A coverage if a patient stays for at least two midnights.
If the patient stays through only one midnight, Medicare Part B, which covers outpatient services, applies instead. As a result, care providers generally try to keep patients in or near the hospital as long as possible while still being able to classify them as outpatients because it’s a more financially sustainable care model.
The second issue is proximity of the outpatient care center to the main hospital. Hospitals are wary of building too many patient beds.
But to be eligible for the federal government’s 340B Drug Pricing Program, which provides discounted prices on outpatient prescription drugs to eligible healthcare organizations, a hospital’s outpatient facilities must be within 250 yards of the main hospital or another eligible outpatient location.
It all adds up to the need for a new payment paradigm, as well as a new design approach.
“What we should be doing as an industry is negotiating with the payers,” Postma says. “We need to say, ‘Don’t pay us for an inpatient and don’t pay us at the outpatient base rate. Pay us for the step-down environment.’”
Day hospitals for cancer care
This type of “step-down” arrangement has already been established in behavioral health, in which day hospitals allow patients to remain close to caregivers while helping patients avoid the costs associated with full inpatient admission. This could serve as a model for cancer care.
Swedish Cancer Institute has begun engaging in design discussions regarding the possibility of a re-envisioned cancer center.
It’s an effort to future-proof their next construction project: Even though rule changes or successful negotiations with payers could be a long way off, they’re attempting to bridge the gap between an ideal future and today’s realities by imagining a new care setting.
Perkins&Will has been working with the healthcare organization to reimagine what this setting could look like for cancer patients.
The concept includes rooms designed for single occupancy because, for immunocompromised patients, sharing rooms with other patients and their visitors is not ideal. Semiprivate rooms are also not optimal for roommates’ mental health, given that they could be in different phases of their cancer journeys.
In addition, participants in novel clinical trials could unknowingly pose health threats to those around them.
“We need to be mindful of the risks associated with new biologic therapies,” Grethlein says. “In some cases, we don’t yet know much about transmission because they’re so new.”
At 215 square feet, a typical single-occupancy room in the proposed concept rooms would include:
- Private bathrooms: Minimizing risk of contamination or disease transmission is essential.
- Entertainment: Soothing environments and entertainment, like wall-mounted screens, contribute to well-being.
- Meals: Patients need convenient and safe ways to order, receive, and consume meals.
Advocating for change
Robin Guenther
As architects and designers, we can’t control the rules governing reimbursables and other problems in our healthcare system.
But we can advocate for change by designing for it. We can look ahead to emerging treatments and create new environments that alleviate as many pain points as we can.
Robin Guenther devoted her professional life to improving patient care.
She gave so much to healthcare architecture and design, and we owe it to her, and to the thousands of patients like her, to address this problem with the same dedication and consideration she would have brought to it.
Marie Henson is the firmwide health practice leader at Perkins&Will (Seattle) and can be reached at [email protected].
