Analysis by JSR Associates, Inc.

By Jane Rohde, AIA, FIIDA, ACHA, NCARB

A survey was sent to the International Interior Design Association (IIDA) Healthcare Forum Members in order to better understand which products are being specified in the healthcare marketplace. This analysis is based on the information received from 194 surveys out of 980 distributed. The survey was conducted by JSR Associates, Inc., on behalf of the Vinyl Institute. Designers from 39 states completed the surveys, with a broad geographical representation.

Trends driving the healthcare design market

Overall, work in healthcare and long-term care markets usually follows the reimbursement path, with the exception of private pay facilities (generally long-term care only). For example, in the long-term care marketplace, rehabilitation and physical therapy are largely reimbursed by Medicare, so it now makes sense for long-term care facilities to accommodate shorter-term residents. Also, market demand has increased for transitional housing facilities with adult day care services for specially abled individuals. In some states Medicaid reimbursements cover both day programs and rehab-transitional stays. Overall savings can be demonstrated to Medicaid by "stepping down" care, as a patient or resident's needs change.

Ambulatory care: Largely because of capitated rates and shorter patient stays in acute care settings, the ambulatory care market is growing, including outpatient clinics/centers, doctors' and dentists' offices, and specialty outpatient services. In addition, the marketplace has become more competitive, so doctors, dentists and other medical professionals are beginning to realize how the built environment impacts their patients' choices.

Individuals - particularly baby boomers - are increasingly taking responsibility for their own health, instead of leaving these decisions to the medical professional. The Internet and increased access to technology make it easier for patients and their families to obtain information about medical practices and alternative therapies. This along with changes in reimbursements for alternative therapies is driving continued growth in the areas of alternative healing, wellness spas and chiropractic services. For the past six or seven years, "wellness" has been a politically correct term in healthcare. Clinics are no longer called clinics; they are "wellness" centers. These centers regularly incorporate space for exercise and physical activity, along with retail shops such as hair and nail salons, spas and juice bars. In response to requests from residents, wellness centers within continuing care retirement communities now include these programmed spaces for their residents.

Acute care: The acute care market is also strong, predominantly with work in emergency rooms, surgical suites, waiting areas and other hospital spaces (predominantly in teaching hospitals). Secondary market work also is growing, particularly with specialty hospitals for children, women and others. Increasingly, designers are attracting clientele by focusing on special markets within acute care on which to build their reputations. To survive in today's competitive marketplace, conventional and community-based hospitals are re-evaluating and re-inventing the ways in which they deliver services to their constituencies.

Long-term care: The predominant project work in the long-term care market is in assisted living (private pay). Due to saturation, this work has reached a plateau in the last few months, but is expected to begin another growth spurt in the near future. In the last 12 to 18 months, many of the larger chains of skilled nursing facilities have gone into Chapter 11 as a result of the capitated rates for skilled nursing. As these organizations come out of Chapter 11, the trend seems to be for mergers, to establish better financial stability, and to focus on a particular area of the marketplace.

The other growing area within long-term care includes either assisted living or skilled nursing facilities catering to dementia and dementia-related disease, driven by an increased senior population.

For low-income and moderate-income seniors, the primary options are skilled nursing or independent living with services built into the operational program. This market segment is tremendously under-served, with skilled nursing facilities closing as a result of capitated rates and resident needs not matching the services provided. Medicaid waiver programs are reviewing the options of personal care services, home healthcare services and licensed assisted living services to meet the needs of moderate and low-income seniors. Another model under review is medical adult day care provided in conjunction with assisted living housing, in an effort to obtain reimbursements for care provided through adult day care or community-based home healthcare. Public senior housing is beginning to compete with market rate senior housing, as social services become available and community amenities are added.

Product Information Results

Overall, the results of the survey indicate that, within their specialty of healthcare design, respondents consider aesthetics, durability, ease of maintenance, client preference and initial cost - in that order - as the most critical product characteristics for all products they specify. Secondary product characteristics are cost of maintenance, infection control, ease of installation, access for wheelchairs (in relation to flooring materials only) and life cycle cost, in that order. In explaining their product selections, some designers factored in the environmental performance of materials, but those attributes received a lower number of responses than other properties. These included whether the material is considered "environmentally preferable" and whether it can be recycled. With the exception of paint, the lowest rating for how a characteristic impacts product specification decisions was given to whether materials off-gas and/or have an impact on indoor air quality.

Some additional observations:

• Vinyl plank flooring, a relatively new product, has become more popular in this market as more spaces are designed with a warm, residential feel. Vinyl plank flooring has a residential look but can be maintained under high traffic conditions and meets the demands of healthcare environments. Designers are using more vinyl plank flooring in all areas of healthcare design - acute care, ambulatory care and long-term care - according to the survey. The only limiting factor is cost, as it is more expensive than sheet vinyl and VCT.
• In healthcare facilities, where carts, vacuum cleaners, buffers, wheelchairs and other equipment can nick or scrape the base, rubber base has an advantage over other base materials because of its "through color" - that is, the face color is consistent throughout the product, not just on the outer layer. Stain grade wood base is most likely used more frequently than paint grade wood base because the base is usually made of hard wood, which holds up better to heavy use than the softer woods. Some respondents also listed hard woods as the species used for paint grade wood base, most likely because they are more durable than the softer woods.
• Upholstery products in the healthcare market must stand up to challenging conditions, including heavy and regular usage, spilled food and beverages. Unlike in other settings, they also must address incontinence, blood born pathogens, bacteria and germs. Until a few years ago, vinyl and laminated fabrics were the only moisture-proof products available for this market. Woven Crypton is relatively new, but its popularity is clear from the survey results. It provides the same durability and ease of maintenance that vinyl provides, with the look and feel of fabric. Interestingly, the reasons designers say they specify vinyl are practically identical to the reasons they specify woven Crypton. The primary difference is in the look and feel - unlike Crypton, vinyl can be "sticky" to the touch.
• It is worth noting that several designers do not know which manufacturers make linoleum versus vinyl flooring materials - or perhaps they confuse the materials themselves. Some also listed manufacturers in the categories of carpet tile, ceramic tile and woven Crypton that do not manufacture these products. This points out a need for manufacturers to educate designers about the properties of each product so they clearly understand what is available and being specified.