HealthPerspec-ves, TheoriesandApplica-on:

TheSalutogenicPerspec-ve
DrPH,FAIA,FACHA,LEEDAP

A.RayPentecostIII

DirectorofHealthcareArchitecture,ClarkNexsen President,AIAAcademyofArchitectureforHealth
Design & Health Malaysia 2010 September 28, 2010

CLARK NEXSEN

Presentation Framework

Topics
1 HealthcareReform:AordableCareAct(ACA) 2 PublicHealthparadigmfordesign 3 SalutogenicDesign 4 Impera-vesofour-me 5 Na-onalSecurity

Design & Health Malaysia 2010

September 28, 2010

CLARK NEXSEN

Presentation Framework

Topics
1 HealthcareReform:AordableCareAct(ACA) 2 PublicHealthparadigmfordesign 3 SalutogenicDesign 4 Impera-vesofour-me 5 Na-onalSecurity

Design & Health Malaysia 2010

September 28, 2010

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Healthcare Reform: Affordable Care Act (ACA)

PredictableImpacts:
1 Con-nueddownwardpressureonpayments

Design & Health Malaysia 2010

September 28, 2010

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Healthcare Reform: Affordable Care Act (ACA)

DownwardpressureonMedicarepayment adjustmentstohospitals,skillednursingfaciliFes,and homehealthproviders DisproporFonateShareHospital(DSH)paymentswill bereduced IndependentPaymentAdvisoryBoardbinding recommendaFonsifMedicaregrowthexceedstargets Similardownwardpressureinprivatepayors

Source:Ms.AbbyBlock,BoozAllenHamilton,presentaFonto2010AIAAAH/ACHASummerLeadershipSummit

Design & Health Malaysia 2010

September 28, 2010

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Healthcare Reform: Affordable Care Act (ACA)

PredictableImpacts:
1ConFnueddownwardpressureonpayments 2QualityisaHIGHPRIORITY

Design & Health Malaysia 2010

September 28, 2010

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Healthcare Reform: Affordable Care Act (ACA)

2012Hospitalvaluebasedpurchasing(VBP);alsofor homehealth,skillednursing,ambulatorysurgery(1) Extension:physicianqualityreporFnginiFaFve(1) PaymentdisincenFves:preventablehospital admissionsandreadmissions,nevereventslist(1) ReinventthepaFenthandoprocess/experience(2) ALOSreducedtogenerallyacceptedbestpracFces(2)

Sources:1Ms.AbbyBlock,BoozAllenHamilton,presentaFonto2010AIAAAH/ACHASummerLeadershipSummit 2Mr.KenKaufman,KaufmanHall,presentaFonto2010AIAAAH/ACHASummerLeadershipSummit

Design & Health Malaysia 2010

September 28, 2010

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Healthcare Reform: Affordable Care Act (ACA)

PredictableImpacts:
1ConFnueddownwardpressureonpayments 2QualityisaHIGHPRIORITY 3 Demandisawildcard:moreorless???

Design & Health Malaysia 2010

September 28, 2010

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Healthcare Reform: Affordable Care Act (ACA)

Morebecauseofthenewlyinsured,orlessbecause costmanagementisnolongerenough? CostpressureistoconvergeonMedicarerates InsucientforoperaFons Issuenotcostmanagement;coststructure(1) LowercostalternaFvedeliverymodelamust Thecostissuemustinvolvebothsupplyanddemand

Sources:1Mr.KenKaufman,KaufmanHall,presentaFonto2010AIAAAH/ACHASummerLeadershipSummit

Design & Health Malaysia 2010

September 28, 2010

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Presentation Framework

Topics
1 HealthcareReform:AordableCareAct(ACA) 2 PublicHealthparadigmfordesign 3 SalutogenicDesign 4 Impera-vesofour-me 5 Na-onalSecurity

Design & Health Malaysia 2010

September 28, 2010

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Public Health paradigm for design

Thefounda7onsofpublichealth Atrst: Interrupt Environment theAgentHost interacFon causing disease Agent

Design & Health Malaysia 2010

Purpose: Preventor manage infecFous disease Host

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Public Health paradigm for design

Thefounda7onsofpublichealth Environment Management andManagement Atleasttwo management ofthe categories: environment Systemsand isalsohighly Opera.ons. important. Agent
FromtheworkofJohnC.Harding

Host
September 28, 2010

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Public Health paradigm for design

Thefounda7onsofpublichealth Haddon Matrix usedto describe injuriesand accidents. ThreeFmes: Environment: past PhysicalandSocial present, future. Two environments. Host
September 28, 2010

Agent
Design & Health Malaysia 2010

FromtheworkofWilliamHaddonJr.

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Public Health paradigm for design

Thefounda7onsofpublichealth Haddon Matrix receiveda thirdaxis: values. Environment: PhysicalandSocial Values included: freedom, cost,s.gma, others.

Agent
FromtheworkofC.W.Runyan

Host
September 28, 2010

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Public Health paradigm for design

Thefounda7onsofpublichealth Withinthe Environment: Factors: Social PhysicalandSocial Cultural context Ins.tu.onal, ofthe Intrapersonal, environment Interpersonal. fourfactors. cultural Agent
Design & Health Malaysia 2010

Host
September 28, 2010

FromtheworkofUrieBronfenbrenner

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Public Health paradigm for design

Thefounda7onsofpublichealth
CausalPies:necessaryandsucientcauses forDisease
Sucient Cause1 Sucient Cause2 Sucient Cause3

A B D C

A B F E
FromtheworkofK.J.Rothman

A C H G

BandCalonearenotsucientforcause;Aisnecessary.
Design & Health Malaysia 2010 September 28, 2010

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Public Health paradigm for design

Whataretheagents? 1. Exogenous 2. Endogenous 3. Threatsofdamagetothehosts 4. Psychosocialstressors,presses,strains

Antonovsky,Aaron,Health,StressandCoping,JosseyBass,SanFrancisco,1982,p14. Design & Health Malaysia 2010 September 28, 2010

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Public Health paradigm for design

Designmanagementstrategies ForAgents: Modify,subsFtute,remove ForHosts: Isolate,relocate,strengthen,adjust ForEnvironments: Filter,dilute,adsorb,clean

Design & Health Malaysia 2010 September 28, 2010

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Presentation Framework

Topics
1 HealthcareReform:AordableCareAct(ACA) 2 PublicHealthparadigmfordesign 3 SalutogenicDesign 4 Impera-vesofour-me 5 Na-onalSecurity

Design & Health Malaysia 2010

September 28, 2010

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Salutogenic Design

Salutogenesis
AproacFveapproachtohealthpromoFonand prevenFon(1) Inherentprerequisitesthatdetermineapersons abiliFestocopeistheSenseofCoherence(2): Comprehensibility:worldisunderstandable Manageability:resourcestomeetsituaFons Meaningfulness:lifemakessense
1Viravong,Khamphira,Salutogeniccommunitybuilding,InternaFonal JournalofWebBasedCommuniFes,Vol.3,No.1,May2007,p3243. 2Antonovsky,Aaron,Health,StressandCoping,JosseyBass,SanFrancisco, 1982,p14. Design & Health Malaysia 2010 September 28, 2010

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Salutogenic Design

Salutogenesis
Keyelementsinachievingacopingstrategy: GeneralizedResistanceResources(GRRs) AnycharacterisFcoftheperson,thegroup,orthe environmentthatcanfacilitateeecFvetension management.(1)

1Antonovsky,Aaron,Health,StressandCoping,JosseyBass,SanFrancisco, 1982,p14. Design & Health Malaysia 2010 September 28, 2010

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Salutogenic Design

SalutogenicDesign
EnhancesandsupportsGRRs PromoteshealthanddiseaseprevenFoninmulFple dimensions Occursatavarietyofscales,fromcommuniFesto personalizedtechnologies Recognizestheimportanceofspacetohealth Ismorethanbuildings:uFlitysystems,infrastructure, landscape,safetyandriskmanagement
Design & Health Malaysia 2010 September 28, 2010

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Salutogenic Design

GeneralizedResistanceResources(GRRs)
SalutogenicDesignenhancesandsupportsGRRs 1. 2. 3. 4. 5. 6. 7. 8. Physical Biochemical ArFfactualmaterial CogniFve EmoFonal ValuaFveamtudinal InterpersonalrelaFonal Macrosociocultural

Design & Health Malaysia 2010

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Salutogenic Design

Canpublichealthshapesalutogenicdesign?
HowdotheseinuencethesuccessofGRRs? 1. 2. 3. 4. 5. 6. Agents Environment(s):PhysicalandSocial Management:SystemsandOperaFons Time:Past,PresentandFuture Values Socialfactors
September 28, 2010

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Salutogenic Design

Thefounda7onsofsalutogenicdesign
CausalPies:necessaryandsucientcauses forHealth?
Sucient Cause1 Sucient Cause2 Sucient Cause3

A B D C

A B F E
BasedontheworkofK.J.Rothman

A C H G

BandCalonearenotsucientforcause;Aisnecessary.
Design & Health Malaysia 2010 September 28, 2010

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Salutogenic Design

Salutogenicdesignelements(Dilani,others)
ResearchsuggeststhatthefollowinghaveaposiFve orsalutogeniceectonindividuals: Socialcohesion,personalcontrol,quiet,soolight, nature,art,music,architectureandbuilding proporFon,socialsupport,uncrowdedspaces,color, comfort,daylight,separaFonfromdailysFmuli,need forfascinaFngsFmuli,goodsleep,ergonomicform.
AlanDilani,PsychosociallysupporFvedesign:asalutogenicapproachtothedesignofthephysical environment,Interna.onalHospitalFedera.onReferenceBook20082009,p.3237.

Design & Health Malaysia 2010

September 28, 2010

CLARK NEXSEN

Presentation Framework

Topics
1 HealthcareReform:AordableCareAct(ACA) 2 PublicHealthparadigmfordesign 3 SalutogenicDesign 4 Impera-vesofour-me:salutogenicapproach 5 Na-onalSecurity

Design & Health Malaysia 2010

September 28, 2010

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Imperatives of our time: salutogenic approach

1.Demographics:BabyBoomers Theyarethree.mesmoreworriedaboutamajor illness(48%),theirabilitytopayforhealthcare(53%) orwindingupinanursinghome(48%),thanabout dying(17%).(1) 2030over65willbe19%ofUS(1in5)(2) 31%ofnoninsFtuFonalizedseniorslivealone(2) 65+populaFoninUSwillincrease36%20102020(2)

1ShannonOBrien,HowBabyBoomerswillchangereFrement,About.comGuide 2AProleofOlderAmericans:2009,DHHS,AdministraFononAging

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Imperatives of our time: salutogenic approach

2.Legisla7vemandate,UShealthcarereform TitleIV(of10):PrevenFonofChronicDiseaseand ImprovingPublicHealth HCreformbillcreatestheNa-onalPreven-on Council,focusedonprevenFon,publichealthandthe healthworkforce.

Goldberg,AlanS.,FederalHealthReformandVirginia:AnIntroducFontotheAordableCareAct,George MasonUniversity,May28,2010.

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Imperatives of our time: salutogenic approach

3.Prematuremortality Werekillingourselvesbariatrics Highbloodpressure,smoking,overweight/obesity andhighbloodglucoseaccountforveyearsoflossof lifeexpectanceinmenandaboutfouryearsinwomen atthenaFonallevel.(1) Today:2/3adults,16%childrenareoverweight(2) 2015:3/4adults,24%childrenoverweightorobese(2)

1CarolPearson,StudySaysPreventableDiseasesReduceUSLifeExpectancy,VOANews.com,April8,2010 2SophieBorland,75pcoverweightby2015,TheTelegraph,UK,July19,2007.

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Imperatives of our time: salutogenic approach

3.Prematuremortalitycon.nued 3four50message 1. 2. 3. 3riskfactors(tobacco,acFvity,diet) Fourchronicdiseases(cardiovascular,type2 diabetes,cancer,chroniclungdisease) 50%ofdeathsworldwide

Architects,urbanplannersandtransportengineers (amongmanyothers)cancreateenvironmentsin whichhealthychoicesareeasychoices.

ChrisFneHancock,Founder,C3CollaboraFngforHealth
Design & Health Malaysia 2010 September 28, 2010

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Imperatives of our time: salutogenic approach

4.Professionalethics Protec-ngthelife,health,safety,propertyand welfareofthepublic NCARBhasasetofmodelrulesofconduct AIAhasaCodeofEthicsandProfessionalConduct AIAhasaNaFonalEthicsCounciltohearcomplaints Statelicensurelawstoprotectthepublic

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Imperatives of our time: salutogenic approach

5.Associa7onalpriori7es Emphasisonhealthinalldesignac-vi-es AIAhosFngaconferenceonDesignandHealthat theAIAheadquartersreectsindustrywidepriority AIAAcademyofArchitectureforHealthrewriFngits bylawstoreectapriorityonhealthcarefaciliFesAND healthybuildings AIAKnowledgeStrategyreecFng5knowledgeareas, includingoneoncommuniFesandpublichealth

Design & Health Malaysia 2010 September 28, 2010

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Imperatives of our time: salutogenic approach

6.Qualityoflifeinuence Salutogenictechnologyempoweringtheindividual Auditoryassistdevices Visionassistdevices Automatedpumpdispensers InjecFblenanotechnologies Safetyalert/personalalarmdevices Motorizedmobilityassistdevices

Design & Health Malaysia 2010 September 28, 2010

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Imperatives of our time: salutogenic approach

7.Informa7onintegra7on:researchfron7ers Clinicalresearchandscienceatthemolecularlevel BlurringthelinesofeducaFonandtraining,single disciplinestomulFdisciplinarythemaFclearning Studyofbrainbehaviorandbiophysiological responsevs.outwardpersonalbehavior AcademyofNeuroscienceforArchitecture Newproductdevelopment Wearenolongervendors;wereintegrators. JimBills,Novell
Design & Health Malaysia 2010 September 28, 2010

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Imperatives of our time: salutogenic approach

8.Demographics:stashortages Prioritytostareten-on,recrui-ng,safety Nursingshortageof1millionby2020(1)(3) All50states,nursingshortageby2015(1) Need30,000moregraduates@year(30%growth)(2) NurseshortagesnegaFvelyimpacFngcareinlong termcare,hospitals,ambulatorycare,studentcare(4)

1April2006,WhatisBehindHRSAsProjectedSupply,Demand,andShortageofRegisteredNurses,Health ResourcesandServicesAdministraFon 2March2008,CouncilonPhysicianandNurseSupply 3NursingShortage,NursingWorldonline,AmericanNursesAssociaFon,2010. 3Dr.PeterBuerhaus,September/October2005NursingEconomics

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Imperatives of our time: salutogenic approach

9.TheBusinessCase Itmakessensenancially Annualsavingsof20%inoperaFonsfromsalutogenic designinhealthcare;15yearcapitalcostrecovery(1) Obesepeoplepay$1429(42%)moreinhealthcare coststhannormalweightindividuals.(2) WemustfocusoncreaFngenvironmentsthat contributetoreduceddemand.

1JohnBrewer,HealthinMindandBodytoDesign,ExseroMagazineonline. 2FinkelsteinEA,TrogdonJG,CohenJW,DietzW.AnnualMedicalSpendingAvributableToObesity:PayerAndService SpecicEsFmates.HealthAairs.2009;28(5):w822w831.

Design & Health Malaysia 2010

September 28, 2010

CLARK NEXSEN

Presentation Framework

Topics
1 HealthcareReform:AordableCareAct(ACA) 2 PublicHealthparadigmfordesign 3 SalutogenicDesign 4 Impera-vesofour-me:salutogenicapproach 5 Na-onalSecurity

Design & Health Malaysia 2010

September 28, 2010

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National Security

Thisisnotjustaboutsalutogenicdesign. Thestakesareexceedinglyhigh. Thecoldwartaughtusalotaboutthevulnerabilityof naFonaleconomies. Newgovernmentreportindicatestheannualrateof growthisnow6.3%,up0.2percentagepoint.(1) MEDICALTREATMENTCOSTSMUSTCOMEDOWN. Itcannotbeonlyaboutmoreecienttreatment; itmustalsobeaboutreduceddemand.

1Obamacare:LowPoliFcs,HighCosts,Theeditors,Na.onalReviewOnline,Sept.13,2010.

Design & Health Malaysia 2010

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Thank You.

Ques-ons?
RayPentecost (757)4555800(USA) rpentecost@clarknexsen.com
Design & Health Malaysia 2010 September 28, 2010

CLARK NEXSEN