Avera tackles stigma of mental illness with style

February 1, 2012


SIOUX FALLS, S.D. — Avera McKennan Hospital & University Health Center is proving the merits of an inventive approach to reducing the fear and stigma that keep many people from seeking mental health care.

Call it architectural advocacy for the mentally ill.

With smart and airy design, the Avera Behavioral Health Center is a bricks-and-mortar testament to the Sioux Falls region that Avera McKennan places its behavioral health services on par with its medical services. And the community has been receptive to the message. Use of inpatient and outpatient services has grown steadily each year since the facility opened in 2006.

"We want to Ônormalize' behavioral health," explained Thomas Otten, the behavioral health center's director of inpatient services. "We want to open up the door that says this is regular health care, use us."

That spirit of welcome and normalcy is evident from the moment one enters under a stained glass transom into a sun-drenched atrium. The lullaby of a waterfall filters through the lobby, and it contributes to the calm of an intimate meditation room, where the plate glass altar wall transforms the waterfall on the other side of the glass into a water wall.

Doves, kites and butterflies flutter through art pieces commissioned from regional artists and inspired by Psalm 139:9-10, "If I rise on the wings of the dawn . . ." The verse was chosen by Avera McKennan's sponsors,

the Sisters of the Presentation of the Blessed Virgin Mary and the Benedictine Sisters of Yankton of the Sacred Heart Monastery, to set the theme for the building.

Sr. Mary Thomas, PBVM, Avera McKennan's senior vice president of mission, said that the soothing ambiance and elegant physical space is intended to make behavioral health patients feel valued. "The ethical and religious directives talk about the dignity of the person. We think that persons who have mental health issues struggle the most to have care that is dignified," she said.

Greenfield opportunity
The 130,000-square-foot hospital and medical office building complex incorporate five inpatient units, an adult day hospital, a research institute for human behavioral genetics, and an electroconvulsive therapy suite for treatment of patients with debilitating, drug-resistant depression. The center is affiliated with the University of South Dakota Sanford School of Medicine Department of Psychiatry and has residency programs in adult and child psychiatry. In affiliation with the South Dakota State University College of Pharmacy, it hosts a pharmacy doctoral-level postgraduate year psychiatry residency.

The hospital's patient assessment center is a free resource for all of South Dakota and three neighboring states. It's staffed by social workers, counselors and psychiatric nurses, who conduct phone-based triage and referral and do in-person assessments for patients who are sent by their doctors or counselors, walk in without an appointment or are delivered by police car. The assessment service meets the federal criteria for a behavioral health emergency service.

Avera McKennan built its $32 million, 110-bed hospital and mental health services office building at a time when many health providers across the U.S. were reducing their commitment to mental health programming. It was the first stand-alone behavioral health inpatient hospital to be built in the U.S. in a decade, said Steven B. Lindquist, Avera McKennan's assistant vice president of behavioral health services. The investment kept faith with the Avera Health system's heritage and overall mission to make a positive impact in the lives of patients and communities.

Based on patient days, psychiatry is Avera McKennan's biggest service. Lindquist said he and other administrators have built a strong business case for behavioral health by making sure the service contributes to Avera McKennan's bottom line. Thatis accomplishedin no small part by the additional revenue from an employee assistance program product line Lindquist started at Avera

McKennan almost a decade ago. Lindquist said 150 businesses in the Sioux Falls region pay per member per month fees to enroll in the service, which now covers 50,000 enrollees in 38 states.

The decision to relocate inpatient behavioral medicine off the main medical campus was a practical one — Avera McKennan hospital was busting at the seams. Fred Slunecka, who was Avera McKennan's chief executive at the time and is now chief operating officer of Avera Health, urged Lindquist and Otten to think expansively in planning for the new behavioral health facility.

"Literally you are building in a soybean field, so you are not going to be bound by foundations or structures from the past. You can design this thing the way it should be for behavioral health," Lindquist recalled Slunecka having said.

Together with BWBR architects in St. Paul, Minn., Avera McKennan executives developed a design for a freestanding facility with amenities that would address the practical, the medical, the spiritual and the social dimensions of behavioral health care.

Avera McKennan and BWBR identified four values that became the bedrock of the project and a type of brand promise to the community. The building had to be safe and secure as many patients might be a risk to themselves or others. It had to be a "world class" health facility, fine-tuned for the practicalities of behavioral health. It had to promote the dig-nity of patients, staff, family members and visitors.

And, it had to convey spirituality in substantive ways.

"Those four value statements still drive every decision we make," Otten said.

Spirituality, dignity
The spiritual grace notes in the design include lots of natural light and scenery. Windows frame calming views of cornfields, the interstate, prairie and sky. Parklike, open-air enclosures give patients places to reflect and play.

The building's skylit entry atrium separates the outpatient medical offices from the inpatient hospital. On the inpatient side, a clever system of double corridors helps protect patients' privacy, a factor of great concern given that Sioux Falls has a population of about 154,000, and it is not inconceivable that a tray passer or support service worker might recognize a patient as a classmate or a neighbor. The double corridor system works this way: A series of doors open from a public hall into an inner room, which could be a family meeting room or a supply staging area. The doors at the opposite ends of those rooms open into the patient areas.

Much of the bustle of a hospital unit occurs around the nurses' station. That's where clinicians routinely have conversations about patients. To keep patients from clustering in the vicinity while allowing the staff to keep them in clear sight, the nursing station in all the units is located at the narrow end of a wedge-shaped common space. There are soft seating areas away from that desk, and group activity areas, including classrooms, at the broad end of the wedge.

Safety by design
Patient rooms skirt the perimeter of the common area. Each room has a "front porch," a space defined by a carpet cutout and a single seat bench. Patients have told the architects that the threshold establishes a sense of personal space and makes them feel safer.

Because suicidality is a concern in behavioral health facilities, doors to the patient rooms are double hinged. If a patient were to barricade the door with furniture, the staff can reverse the swing of the door to enter the room.

The sleeping rooms are intentionally stark and sparsely furnished, without a phone or TV. Patients are encouraged to participate in therapeutic groups and activities and may spend very little awake time in their rooms. The ceilings are hard surfaced and 9-foot-high to make it difficult to hide contraband.

Most suicide attempts in behavioral health hospitals happen in bathrooms, often by hanging, and that is one of the areas that the design team spent the most time on. Otten said the goal was to make the room safe without giving it a prison-like feel. There is no exposed plumbing, the showerhead is rounded. Bathroom hardware including safety bars have struts that fit flush against the wall so they can't be used to tie off a cord. The shower curtain is suspended with Velcro strips. The handleless bathroom door unlocks from the inside, but it can only be locked from the outside. In the adolescent unit and the acute adult unit, patients have to ask a staff member to unlock their private bath. When the bathroom light switch is turned on in any patient room, it activates a light signal at the nurses' station.

Placement by acuity
Functional design is only window dressing in the absence of effective programming and therapies. Dr. Matthew Stanley is a psychiatrist who serves as Avera McKennan's medical director for behavioral health. He said one of the chief advantages of the center is that clinicians can segregate adult patients based on their acuity level into one of three units. One unit is reserved for the most acutely symptomatic patients, including people admitted for involuntary, court-ordered, 24-hour holds. Manic and psychotic patients and people in the throes of a severe drug withdrawal are cared for here, where the emphasis is on intense observation, safety and medical management.

The second adult unit is focused primarily on voluntary patients who have major depression, anxiety disorders or personality disorders. Care may include cognitive behavioral therapy, dialectical behavior therapy or immersion education to build daily coping and living skills that lower the risk for relapse and readmission.

The geriatric/dementia care unit is for patients with diminished mental capacity, whose conditions may be complicated by a constellation of symptoms, or aggravated by adverse drug interactions or their living environment, usually in a nursing home. They may be psychotic or aggressive. The unit is attached by an indoor walkway to the adjacent heart hospital and emergency room.

The floor in the geriatric unit is laminate, a material chosen because it is safer and easy to sanitize. Otten said that in addition to harboring odor, carpeting can be a problem if it has a pattern because some dementia patients perceive patterns as cliffs. "They get locked into place," Otten said.

The two children's units are age segregated. Avera takes patients as young as 4. Patients age 13 to 18 are assigned to the adolescent unit. A decision to admit a child to the hospital may be based on the potential for the child to hurt him or herself, or others. They may exhibit psychosis or depression that does not respond to outpatient treatment.

Children have less control over their environment outside the hospital than do adults, and Otten said staff address this throughout a child's stay by getting families involved in the treatment. There are family meetings with staff when a child is admitted and discharged, and sometimes during the stay. There are daily phone calls with parents or guardians, Otten said. "We're focused on giving and getting information so we don't make this change for a child and put them back into the exact same environment that could have contributed to the child's anxiety, stress or depression. Ultimately, our goal is to partner with the family to support the recovery process."

Otten said family involvement is encouraged in the treatment and recovery of all patients. All patients are discharged with individualized plans for follow-up care. "We totally believe you can recover from a mental health diagnosis; sometimes that means living with medications," he said.

Avera McKennan's behavioral health has a long reach

The influence of Avera Behavioral Health Center reaches across South Dakota, a rural state with a population of about 814,000. As is typical of other states, South Dakota's psychiatrists are clustered in urban areas, most notably Sioux Falls, the state's largest city and home to Avera McKennan Hospital & University Health Center and its behavioral health center. But the need isn't localized, so Avera McKennan's staff psychiatrists hold regular outreach clinics in rural communities.

Dr. Matthew Stanley, the psychiatrist who is Avera McKennan's medical director for behavioral health, said rural communities may have mental health counselors or primary care providers who can treat mild to moderate depression or other mental illness once a patient is stabilized and on the proper drug regimen. Visiting psychiatrists tend to function as diagnosticians and prescribers with an expertise in psychotropic medicines. They provide ongoing oversight care to patients with chronic, potentially debilitating conditions including schizophrenia and bipolar disorder.

Avera McKennan's psychiatrists treat patients remotely too. Telepsychiatry is the busiest telemedicine service at Avera McKennan. Behavioral health staff regularly participate in emergency behavioral health consultations involving patients at rural hospitals and clinics. "If you are in rural South Dakota and you have a major depression or schizophrenia, there aren't a lot of available clinical options and the use of telepsychiatry and outreach clinics helps to address these needs," said Stanley.

Avera McKennan Behavioral Health staff broadcast monthly psychiatry grand rounds to clinics and hospitals around the region. They also broadcast monthly forums on child and adolescent psychiatric disorders to school counselors and teachers. These educational events are transmitted through the Avera Health system's interactive video network. At times up to 20 rural sites join these conferences. The sessions are archived on the Avera Behavioral Health web page.


Copyright © 2012 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.

Copyright © 2012 by the Catholic Health Association of the United States

For reprint permission, contact Betty Crosby or call (314) 253-3490.