Retail businesses across the country are abandoning brick and mortar locations in favor of building their online presence. This has opened many opportunities for health care providers to reuse underutilized retail spaces.
These spaces have many characteristics that health care organizations desire — single floor at grade; large, open floor plates; ample floor-to-floor height; abundant parking; and good visibility from the street. Additionally, these existing sites and structures can offer an excellent opportunity to get a design vision executed with enhanced speed to completion over a conventional ground-up health care facility project.
However, they also come with hidden challenges that must be addressed for a successful project.
Opportunities and risks
Early assessment of the opportunities and risks of the adaptive reuse of a retail site for health care use is key to a successful design and is an essential first step as many of the items need to be considered during lease negotiations. To assess the conversion, it is essential to start with zoning and site issues as well as focus early on infrastructure costs that can impact long-term operational costs.
Facility sites. Retail sites often start with good visibility and street access, as well as ample parking. Additionally, an easy-to-understand site is essential. Patients often are stressed and distracted by the mere act of going to see a doctor. Finding the location, entering the site, and parking often set the baseline for the patient-satisfaction level well before they even get to the front door.
A typical patient is also vastly different from an able-bodied shopper. Although they both have a desire for parking close to the front door, a patient has significantly less capacity to handle a long walk from a remote corner of the lot. This often sets a need for patient drop-off zones, with partially or fully covered canopies. Large quantities of accessible parking also may be required by code. If available on the site, it may be advantageous to include some accessible parking within a garage to allow patients to get out of their vehicles while being protected from the elements. Often organizations include special parking for patients with special needs such as oncology patients who have suppressed immune systems.
Architectural design. Wayfinding elements are more memorable than signage and become key parts of the patient journey. At Penn Medicine Cherry Hill (N.J.), a metal panel wall marks the entry to the building and is visible from the entry to the site and throughout the parking area. The wall continues into the two-story lobby as the dramatic backdrop and a wayfinding element throughout the visit.
Although many of these former retail buildings have the site advantages essential for successful outpatient facilities — the existing structures are often less appealing visually and are not in alignment with the health system brand. Transformation of these simple boxy structures can range from recladding to complete reconstruction of the exterior skin and may include cutting in new windows or skylights. With buildings often set along a congested highway or within a shopping plaza, bold and simple design concepts and gestures are essential. This can be achieved in a variety of ways depending on the project context, owner goals and design vision.
At Main Line Health Center at Exton (Pa.) Square, the health care tenant and mall owner desired to create a design image that merged the modern building imagery from their existing facilities with the modern farm imagery of the mall. The final design concept marks the new entry and drop-off area and incorporates expressed structure with horizontal wood slats and a vertical perforated metal panel. The finished concept creates a simple, but easily identifiable point of entry.
At AtlantiCare Health Park Manahawkin (N.J.) and Penn Medicine Cherry Hill, the strategies were similar — adapt the existing building massing to create the new desired relationships and create an image that aligns with the owner brand and patient experience.
For AtlantiCare, this included creating building volumes that mark the corner and a glass vestibule as the point of entry at the center. At Penn Medicine, the building massing is enhanced with bold color in large panelized modules to articulate the new building façade while the relocated building entry is marked by a white metal panel wall which pieces through the exterior. This monumental, two-story metal panel wall is washed with daylight and is the focal element of the skylit lobby.
Designers should keep things simple by working with what they have in the existing structure to maximize cost savings. Tall and thin windows may satisfy the design intent and be simpler to cut into the exterior wall. In other locations, removing entire portions of the exterior wall may be simple and provide dramatic natural light at lobbies and key spaces. Early assessment of the existing wall assembly is key as the structure and energy efficiency may require extensive rework to be notated in the lease terms, and tenants are often getting the space as is.
Dramatic entries and public spaces can be created that take advantage of a building’s high visibility and floor-to-floor height. Due to the retail use and building codes, there is often ample ceiling height to create bold entries, dramatic lobbies and large circulation spaces. Additionally, use of a large lobby volume can help to break down the scale of the existing building by giving patients a central point to return to throughout their visit. Skylights and windows are important components for the previously windowless boxes and can add natural light for patients and staff.
Structural considerations. Understanding the existing and proposed building systems will impact first cost and life-cycle costs. As with the location, the building’s structure should be assessed early for suitability for the new use. Bar joist structures are common in retail, and the long span between columns can provide flexibility in planning options at Day 1 and in the future. However, if fire ratings are required, spray fireproofing the bar joists can be costly and messy. In multiple projects, the steel structure and exposed ceiling have been highlighted as part of the design concept.
At Main Line Health Center at Exton Square, the health care organization sought to create a nontraditional design solution to reflect the nontraditional business strategy of putting a health care center in an enclosed mall. This included exposing the structure along the main public walkways and painting it charcoal gray, which was contrasted by clouds of white acoustical ceiling tiles over the waiting area. The effect created a subtle pathway to guide patients and visitors to the centralized check-in at the center of the space.
At Penn Medicine Cherry Hill, the project site included a non-fireproofed steel structure with a challenging floor-to-floor height. A design concept was developed that exposed the clean structure above, allowing the public spaces to feel more open. A warm color scheme was used with a light tan color on the exposed columns, joists and deck above, contrasted by the white metal panel feature wall, terrazzo floors and walls with splashes of teal as accents. Departments are defined with accents of color in wall finish and furniture, and touches of wood add warmth to the palette.
Additional consideration is needed for floor leveling and fire ratings. In retail, there is little concern with a floor that is not flat and level, as this is not perceivable due to the large open spaces. However, health care spaces have more stringent tolerances for equipment, doors, partitions and even Americans with Disabilities Act requirements. Early identification of the required ratings is essential. With tall floor-to-floor heights, rated partitions become expensive and often the existing structure is not rated. With some older facilities, the floor decks have been unable to obtain a rating required, necessitating discussions with the authority having jurisdiction.
Mechanical aspects. Retail facilities are drastically different from health care spaces with regard to mechanical systems. To meet the demand for conditioning requirements and air changes in health care, increased airflows and cooling capacities are needed.
In the retail setting, systems are designed to serve large, open spaces with minimal controls specific to the different building zones. Additionally, these units are often designed to use outside air efficiently instead of conditioned air if the temperature ranges are adequate.
In contrast, even the most basic health care spaces have multiple control points and zones to manage as exam rooms, waiting rooms and staff spaces all have different needs for temperature controls and setpoints. Equipment spaces also may need dedicated systems to comply with specific requirements.
Multizone units require air valves to regulate individual zones, each of which has terminal reheat coils not normally found in retail settings, requiring either inefficient electric reheat coils or a hot-water reheat generation and distribution system. The bottom line is added cost at Day 1 to replace the existing equipment or long-term operation costs due to high electric usage.
Additionally, humidification/dehumidification systems are nonexistent in the retail setting and rely heavily on outside air when the temperature is in the appropriate range. Not surprisingly, complex health care spaces such as operating rooms, imaging equipment and compounding pharmacies have strict minimum and maximum humidity ranges dictated by code and may impact the facility’s ability to serve patients or receive reimbursement for services performed. Even simple outpatient facilities may have similar minimum and maximum humidity ranges for patient comfort and for safe storage of clean supplies. These systems, in turn, require digital controls throughout the building to maintain, monitor and track proper levels of temperature, humidity and pressurization.
Plumbing challenges. It is also common to see scalability challenges with plumbing systems. Typical retail spaces have a few toilets for staff and visitors while health care facilities have functional requirements that typically exceed the minimum code requirements for retail buildings. With requirements to separate restroom facilities for public, staff and patients, even small facilities have three to four times the number of fixtures. The cumulative effect of the additional fixtures may require new water and sanitary services.
Health care providers also have a need for additional reliability in systems, which typically translates into increased size and quantity of hot-water heaters. Codes also may dictate the output temperature for various fixtures. For example, exam room sinks and janitors’ closets need to be at different temperatures requiring separate temperature loops or mixing valves to lower temperatures and boosters to raise temperatures at the point of use.
Finally, most retail facilities are built on a concrete slab on grade. The additional fixtures necessary for health care require significant cutting of the slab and trenching.
Electrically speaking. Health care facilities also have increased requirements for electrical system capacity, due to higher energy consumption and the move to electronic health records — wiring, distribution of normal and emergency equipment, and applicable design codes are all considerations.
Fundamentally, power consumption is greatly increased because there are more people and equipment using it. In the retail setting, lighting combined with the heating and cooling loads represents nearly 70 percent of the total energy used, and can range from 10 to 14 watts per square foot. In outpatient health care, greater demands from the mechanical systems combines with additional equipment, computers and monitors to generate higher electrical usage, which typically ranges between 14 and 22 watts per square foot.
An additional consideration is the voltage required for specific diagnostic and treatment equipment, which often needs 480Y/277V power instead of the 208Y/
120V commonly used in retail. As a result, outpatient health care may require a new electric service from the local utility company.
Wiring and distribution also can pose challenges, as retail is allowed to use metal-clad cable for branch circuits, while health care may exclude such cable depending on space type and applicable code.
Perhaps the most significant electrical requirement is emergency power. Whether driven by code or user requirements, emergency power via a generator is common to most larger facilities. As more treatments shift to the outpatient setting, there is increased demand for sufficient emergency power for lighting and equipment.
If facilities professionals can manage the risks, the opportunities for unique solutions found in adaptive reuse projects are limitless and may provide opportunities to increase project delivery speed and create truly unique health care destinations.
Scott Huff is a senior associate, project manager and Philadelphia sector leader for health care at Stantec. He was assisted by Stantec’s Mila Beaver, electrical engineer, and Steve Spellman, mechanical engineer. Huff can be reached at Scott.Huff@stantec.com.