Nowhere in the nation do the three components of healthcaresTriple Aimbetter patient experience, better health of populations, and lower

per capita costsbecome more visible than in rural communities. Local hospitals play an important role in improving health and managing healthcare and patient costs by providing primary care, diagnostics, and outpatient services directly to their constituents. n reciprocal fashion, these facilities, providers, and users contribute substantially to a rural communitys economy. !ut sustaining local healthcare is arduous" ts not easy to recruit top physicians to rural areas, and patients often migrate to more urban healthcare centers for perceived better care. Additionally, small communities rarely have access to the finances necessary to build and sustain facilities outfitted with modern medical technologies, procedures, and e#uipment. n an era of increasingly limited resources, how can healthcare design professionals create and deliver facilities that achieve the Triple Aim$ %o#uille &alley 'ospital in %o#uille, (re., provides an example of what might be accomplished. A community vision 'igh up an (regon coastal hillside, among former log mill director home sites, stands the original )*+* %o#uille &alley 'ospital ,%&'-. !uilt by a consortium of three regional logging mills for the care of their employees and families, this rural critical access hospital has been modified considerably over time to include outpatient diagnostic and surgical services. The facility serves three aging communities" %o#uille, .yrtle /oint, and /owers. 0ey sta1eholders at %&' wanted to ensure their community had a hospital designed to meet and evolve with its growing outpatient and inpatient care needs. They also needed an attractive recruitment tool for new physicians, as several of the hospitals doctors were prepared to retire. The vision was a hospital capable of providing the %o#uille &alley communities with sustainable, local, #uality healthcare, featuring new medical procedures and technologies, and the most respected physicians in the region. To accomplish that vision, %&' enlisted three advisers to help with the initial planning" 2troudwater Associates ,strategic and business planning-, The Neenan %o. ,space planning, site assessments, and design3build services-, and 4ougherty .ortgage ,financing services-. These advisers formed a team with 1ey %&' sta1eholders to collect and evaluate mar1et data, and to subse#uently design alternative operational strategies and facility solutions within a sustainable financing threshold. Leadership, including physicians and staff, participated in a planning session to align uponmar1et data, mar1et capture, possible strategies for growth, enhanced service lines, forecasted financial5operational models, sustainable borrowing capacity, a targeted capital budget, and a conceptual design to deliver on the operational strategy. The 2troudwater, Neenan, 4ougherty, and %&' team tested and retested each scenario against the hospitals specific strategic, financial, and operational goals, which included" ncreasing nursing efficiency with a common nurses station for med3surg, obstetrics, and the emergency department mproving patient experiences 4elivering private patient rooms 6nhancing patient access 7ecruiting internal medicine physicians ncreasing orthopedic procedures.

!ased on this collaborative design process, the pro8ect team developed 934 architectural animations, staff and patient flow simulations, and ! . models to supplement financial operations forecasting, staffing, and capital costs models. deal for flexibility and #uic1 manipulation, these models evaluated multiple facility design solutions capable of meeting an overall targeted annual staffing and debt service budget. This process saved a tremendous amount of time, increased engagement, and reduced the costs of misunderstanding and re3 wor1. t also resulted in a :;<.+ million replacement facility si=ed within the hospitals financing capacity and capable of increasing" /atient days and average daily census by + percent (utpatient surgery by > percent 7adiology cases by 9 percent Lab cases by < percent %ardio pulmonary cases by < percent 6mergency department visits by + percent.

Next, the pro8ect team sought facility funding through the ?.2. 4epartment of 'ousing and ?rban 4evelopment ,'?4- and the (ffice of nsured 'ealthcare @acilities ,2ection ;<; .ortgage nsurance /rogram-, which results in a capital cost substantially below what a rural hospital could accomplish independently. %&'s cost of borrowing was reduced to a net interest rate of 9.A+ percent at a time when taxable debt was trading at + to > percent. Meeting the goal (pened in ;B);, %&' today is a three3story, +B,BBB3s#uare3foot facility with private patient roomsC obstetrics and emergency departmentsC imaging services including %T and .7 capabilitiesC a three3room surgical suiteC pharmacy, lab, physical, cardiac, and respiratory therapy servicesC administrative spaceC educational areaC and *,BBB s#uare feet of covered par1ing. %&'s glass3walled atrium lobby enables physicians and users access to both the upper and lower hillside clinics as well as the hospitals collocated diagnostic and procedural services. The patient rooms are positioned with views of a timbered ravine and the lush, open meandering %o#uille 7iver &alley to the west. These design features have enhanced patient access to private medical services as well as efficient staff to patient ratios, improving the amount of care provided by each full time e#uivalent ,@T6- employee. %&'s average daily census has also doubled ,significantly more than the pro8ected + percent growth- while patient care volumes and mar1et capture have also significantly surpassed pro8ections in every service live. 6ven with increased volumes, %&' has held staff and staff salary increases to ; percent annually, after an initial planned )B percent increase in the first year. @inally, %&' has been able to recruit two of the regions top internal medicine physicians and an established orthopedic surgeon to commit his entire practice to %&'. Setting an example ?nderstanding and sustaining the profound connection between healthcare facilities, local economies, and communities is paramount if healthcare leaders are to improve population health and manage total healthcare expenditures. An active collaborative design process for replacement facilities enables sta1eholder buy3in, improved operational performance via

facility design, and access to sustainable financing. t also creates a facility capable of attracting and retaining healthcare providers and providing competitive care. 6arly indications on year3to3date statistics at %&' for ;B)9 substantiate continuing operational growth and success, yielding an example for the potential future of investment in rural healthcare facilities. Michael Curtis is vice president of The Neenan Co. (Fort Collins, Colo.) and can be reached atmichael.curtis@neenan.com. Brian Haapala is mana in principal at !troud"ater #ssociates ($ortland, Maine) and can be reached at bhaapala@stroud"ater.com.