In many cities, urban medical campuses grow even faster than the downtown core. They are constantly under pressure to create facilities that allow them to stay competitive in a dynamic marketplace. However, this growth frequently comes at the expense of the social and physical environment that surrounds them. As the health care industry continues to expand, recognition is growing of the importance of vital host environments. The speed at which medical campuses expand underscores the necessity for collaborative engagement. Creative planning and urban design solutions are evolving that can accommodate projected institutional growth and increase the vitality of adjacent neighborhoods.
Medical centers and neighborhoods share a tangled history, but the stakes have never been higher for cooperative action on mutual interests. Patients, visitors, employees, and neighborhood residents all stand to benefit from vital campus and neighborhood environments. The paradigm of hospitals simply buying up adjacent property whenever it becomes available has proven to do more harm than good for both medical centers and their neighborhoods. However, institutional expansion does not have to contribute to the decline of adjacent areas.
Sharing tight quarters can break down the best of relationships, but living cheek by jowl for more than 100 years would test anyone’s mettle. Imagine one neighbor that grows faster, demands more space, consumes more resources, and becomes famous, eclipsing the humbler day-to-day struggle of the other.
Most major urban medical centers operate on a global platform of science, innovation, business, and rapidly evolving clinical care. They require highly specialized facilities that demand adjacency, often forming impenetrable megablocks. Patients may come from local neighborhoods, the region, or even from elsewhere in the country or the world, drawn by the expertise of the doctors and the specialization of the care.
Building out, building up, and building away are three models
for institutional growth.
These medical campuses have become practically irreplaceable because of their investment in specialized facilities. Institutions have become the most stable features in the urban landscape; however, outside forces continually pummel them. Because they are regulated industries, government policies on Medicare reimbursements, health insurance, and bed count affect the basic business model. Technology’s rapid advance creates new scenarios for diagnosis and treatment, and facilities undergo constant change to keep pace. Hospital mergers and ongoing competition also shape the delivery of health care.
Around these fixed institutions, demographics and the urban environment are in a constant state of change. In the United States, rapidly growing cities are now rare. The population in some center cities is half what it was in the early 20th century, and wealth has migrated outward, with only some resurgence in the past few decades.
Institutions look to the long term, and neighborhoods endure as physical places from one generation to the next. Individuals in a community, however, have much shorter time horizons. Residents, landlords, storekeepers, and developers need to make day-to-day decisions: should we replace the boiler? should we invest in a new roof? should we build? will we be staying or moving?
In short, the world view of a medical center could not appear more different than that of a community. The two have more in common, however, than appears at face value. Both struggle with real or perceived issues of urban safety. The needs for a well-trained work force and access to high-quality jobs are related aspirations. Employees and residents both seek high-quality housing and the complement of good schools, convenient retail businesses, and nearby recreational facilities. Both medical centers and communities exist in a civic realm and need attention from government agencies that are beset by a multitude of other problems.
Mediation between two individuals who do not see eye to eye is at least straightforward. Medical centers, however, are themselves multiheaded organizations, representing the interests of doctors, patients, administrators, educators, researchers, and, in many cases, multiple, even competing institutions. Likewise, communities are an assembly of many individuals who may coalesce into groups, but leadership can be diffuse. Also, community organizations may lack funding or capacity, and multiple nonprofits may coexist each with a slightly different agenda.
Change is not impossible, however, and many medical centers and communities are trying new ways of working together. Medical districts in Baltimore, Boston, Buffalo, and Philadelphia have launched initiatives to work more closely with surrounding communities, offering lessons for other cities.
Faced with inevitable growth demands on many fronts, medical centers employ three classic strategies to fulfill their mission. In practice, these models blur over time and most institutions draw on all three. They are:
- Building out: institutions acquire land on the periphery and grow outward;
- Building away: institutions disperse units of operation away from the center of campus to enable more critical services to expand; and
- Building up: institutions demolish older, obsolete buildings at the core and grow vertically.
East Baltimore. Investment decisions are
dependent on security of tenure.
Building out has been the traditional way to secure an unpredictable future. Sprawling land resources make it possible for medical centers to phase in programs as needed—often in low-density buildings. The perimeter accommodates surface parking while allowing for potential expansion. The problem on the periphery, however, is a constantly destabilized neighborhood and erosion of city fabric. Ultimately this strategy has become more difficult, with communities getting better organized, city regulations getting tighter, and valuable urban land getting more expensive.
Building away became attractive for two reasons. As central campuses reach capacity and land on the periphery becomes less available, medical centers seek to identify nonessential programs that can move outside the core. Employee parking, supply-chain facilities, and back-office functions can survive in satellite locations as long as shuttles and telecommunications are well managed. Satellite operations also provide a means to reach an increasingly dispersed population. Patients find it easier to receive primary care and even some diagnosis and treatment in medical office buildings closer to home. The main campuses in the inner city have become highly specialized tertiary- and quaternary-care destinations, complemented by facilities in the suburbs or other areas where the population is growing. Partnerships with smaller hospitals in the region also have become a way to deliver health care far from the main medical center.
Today, many medical centers in urban areas are faced with building up. Surrounding properties are not available for economic, political, or social reasons; remote and satellite facilities are at capacity. Core programs are competing for locations at the absolute center of the campus. Adjacency between clinical care, research, and education fuels interaction and drives innovation.
Redevelopment of obsolete buildings and infill development on surface parking lots put premium land to the highest use where clinical care, education, and research can be integrated in new facilities that are constructed taller and closer together. When well executed, this strategy can lead to high-quality, walkable environments well served by regional transit and close to a concentrated workforce. But when done poorly, these campuses can become internally focused precincts walled off from adjacent neighborhoods.
Partnerships become an essential vehicle for addressing joint interests in a dynamic context. The stakes for both institutions and their neighborhoods become too high for them not to cooperate, especially as land becomes more scarce, operating costs rise, and the need to engage the city becomes imperative. Three types of partnership exist—umbrella entities, joint entities, and distinct organizations.
Umbrella entities .This first form of partnership is among the institutions themselves. Most downtown medical centers today are amalgams of sister institutions, competing institutions, or spin-off institutions. Each entity has its own board and defines itself with a distinct mission. Their real estate holdings may not always be contiguous. Ambitions for growth vary, and capital resources can be unequal.
Umbrella organizations within a medical district provide a forum for ongoing engagement that can lead to joint planning; coordinated development; shared security, parking, energy, and other operations; negotiated services; and unified neighborhood and government relations. Funding to support staff and other operational costs within the organization may initially be generated by member assessments, much like a business improvement district. Ultimately, project and parking fees can provide more sustainable revenue streams.
East Baltimore Development Inc. has
been investing in the renovation of
traditional rowhouses while planning
for a new school campus and
a proposed transit station.
Joint entities .A second model for partnership focuses on the relationship between the neighborhood and the institutions. In this model there is likely to be more focus on neighborhood revitalization and redevelopment projects in the transition areas. The organizational structure should include foundations, the city, or other nonprofits that can help maintain the balance between institutional and community interests. These organizations can bring professional expertise and city attention to otherwise neglected neighborhoods while building capacity in the community. Funding to support a joint organization may come from a combination of institutional assessments, foundations, government sources, and project fees.
Distinct organizations .A third form of partnership involves having two separate organizations—one as an umbrella for the medical institutions and one as an umbrella for disparate community groups. This model allows constituents of each group to concentrate on their primary areas of interest, although a strong working relationship among members of the professional staff of each group, if not the boards, is necessary to pursue areas of mutual concern and benefit. Unless there is a strong real estate market, however, the initial startup and ongoing funding for a full-fledged community development corporation (CDC) may require institutional participation as well as funds from other third-party sources.
In all cases, these nonprofit partnership organizations should have a representative board and a professional staff to move an agenda forward. Regular meetings should establish a forum for identifying shared concerns, tackling points of conflict, and finding solutions. With board leadership, the executive director and staff should build bridges to the city, pursue outreach to foundations and other funders, and engage sister organizations, whether serving neighborhood, downtown, or institutional interests.
Areas of common ground between communities and institutions do exist. With thoughtful planning and in collaboration with partner community groups and the local government, medical institutions can play the role of catalyst in neighborhood revitalization. Among the areas where this collaboration can produce results are the following:
- Transit. Transit infrastructure has the longest lead time but offers the greatest rewards to all parties. Institutions need employees to get from their homes to the workplace; inner-city residents often need transit to improve their job opportunities elsewhere. In this situation, the clout of an institution can capture the attention of regional and federal agencies that must decide how best to allocate scarce resources. Because most medical districts are in inner cities, rail infrastructure may be nearby but inadequate, creating the prospect of improved service through construction of a new station, increased frequency of service, or addition of bus rapid transit.
- Housing and community development. Distressed neighborhoods often suffer from a pattern of disinvestment, abandonment, demolition, and vacant lots. The market for new housing suffers from negative perceptions and real safety issues, which affect new and existing residents equally. Institutions can provide financial incentives for employees to live in the neighborhoods and also can add to the capacity of local CDCs to build affordable housing. Retail businesses are more likely to succeed with increased residential populations, especially if hospital employees are also consumers.
- Safety. Safety is a shared concern for all, whether it is a parent trying to raise a child or a hospital employee working the evening shift. Business improvement districts have pioneered cleaning and safety programs that put ambassadors on the street, either on foot or on bicycle. Institutions can also extend their security services into the neighborhood to benefit both employees and residents.
Planning for the Buffalo Niagara Medical
Campus in downtown Buffalo, New York,
has spurred reinvestment in adjacent properties
Jobs. Building wealth for existing residents is a function of connecting them to jobs. Workforce training must go beyond the typical efforts and focus on outreach in the schools and basic work readiness issues, often delivered best by community organizations with a deeper understanding of their clients. Community colleges are in the best position to deliver programs but are more successful when medical centers can identify job needs and communities can identify student learning needs.
- Schools. Strong neighborhoods have good schools. This asset provides opportunities for existing residents, and attracts young people and keeps them in the community once they have families. For institutions, access to good schools can be a tipping point for employees deciding where to live. In several cities, institutions have been the catalyst for demonstration schools that combine community services, excellent education, and after-school activities.
In this new urban landscape, a more defined medical campus lives and grows within its borders. The edges become essential seams and create a zone that mediates between two healthy districts rather than a wall of defense. Medical office buildings, clinics, and incubator buildings relate to the city at large and to the medical campus. Graduate student housing, housing for medical residents, and other mixed-income housing can also significantly enliven the edges of the medical district.
Medical buildings often have a larger footprint and greater parking needs than can be met in an older neighborhood, however. Their design must be sensitive to the existing scale and massing to provide a transition from high-rise medical, academic, and research facilities in the center to the more domestic scale on the perimeter. Whereas too much height may overwhelm a neighborhood, the counterpart of sprawling one-story buildings is equally problematic: an urban context demands that active commercial streets be lined with buildings at least two or three stories tall.
With additional density, surface parking becomes an opportunity cost for new infill buildings. Parking is forced either off campus or into structures, and every effort should be made to reduce total parking requirements. Wherever structures are located, they should follow strict guidelines applicable to any well-designed urban setting: placement of parking in the center of the block, active ground-floor uses lining the parking structure, minimal creation of blank facades, and responsive design detail on facades that face the neighborhood.
The Longwood Medical Area in Boston.
As land resources become scarce, managing
density becomes essential.
Because construction of a new high-rise building in the center of a medical district brings more floor area on line at once, creative cooperation between different departments and institutions may be required to fill it. Designing flexible space may be a way to accommodate interim uses, because over time, clinical care and clinical research uses eventually will expand to command the prime properties in the medical district. New partnership organizations can help coordinate the complex programming, funding, and phasing required for a base building, addressing the challenges of different funding streams and timelines.
Any property in the center of a medical campus is valuable as a building site, but a network of public streets remains a useful framework to provide access for patients, visitors, and employees, as well as residents in the surrounding neighborhood. Buried in the center of many institutions are food courts, banks, gift shops, and offices that could get exposure along the street frontage, increasing visibility and foot traffic while activating the streets.
Despite past antagonism, medical centers and communities have too much at stake to ignore each other. Both stand to benefit from a shared future, but need new forms of partnership to promote dialogue.
The problems of the inner city—safety, abandoned housing, lack of services, weak transit connections, unemployment, and poor schools—constitute shared concerns. Beginning with dialogue and moving toward a unified voice, medical centers and community groups can work together to find solutions, seeking outside funding and attracting the attention of the city when needed.
Working within well-defined medical center campuses, institutions are finding that they have to engage in infill development and build vertically. A network of streets and careful management of scale and use in transition zones builds a more positive relationship with the surrounding neighborhood. Joint action on transit improvements, mixed-income housing, education, and workforce training sets the stage for a stronger community and a healthier neighborhood—elements that are to everyone’s advantage. The true opportunity for the medical campus of the future lies in leveraging the relationships between partners and in seeking stronger connections with the adjacent neighborhoods.
Reprinted from Practicing Planner, the online publication of the American Institute of Certified Planners, an institute of the American Planning Association; copyright 2011 by the American Planning Association.