Designing for Rural Health by LS3P

DESIGNING FOR RURAL HEALTH LESSONS FROM PENDER COUNTY

ACKNOWLEDGMENTS THANK YOU TO OUR SPONSOR, PARTNERS & COLLABORATORS KATHERINE PEELE LS3P DANNY ADAMS LS3P DAN HARROP LS3P BRIAN WURST LS3P ESPY HARPER LS3P RON SMITH LS3P MICHAL COLE COLE JENEST & STONE PATRICK HOBGOOD HOBGOOD ARCHITECTS TAYLOR SIMMS NEW HANOVER REGIONAL HOSPITAL NICK GALVEZ OFFICE OF RURAL HEALTH, NC DEPARTMENT OF HEALTH AND HUMAN SERVICES

LIZ PETERSON NCSU COOPERATIVE EXTENSION HEATHER KELEJIAN NCSU COOPERATIVE EXTENSION KERRIE BRYANT PENDER COUNTY HEALTH ASSESSMENT ANGELA LIVINGOOD PENDER MEMORIAL HOSPITAL HEATHER KELEJIAN NCSU COOPERATIVE EXTENSION CLIFTON MARSHALL CURRIE COMMUNITY CENTER JORDYN APPEL-HUGHES FEAST DOWN EAST PROGRAM DIRECTOR

SUSAN BULLERS LOCAL RESIDENT, PHOTOGRAPHY CLIFTON MARSHALL MORRE’S CREEK MISSIONARY BABTIST CHURCH

KIM GORE MORRE’S CREEK MISSIONARY BABTIST CHURCH

CONTENTS BRAINSTORMING SOLUTIONS 8 10 11 11

THE COLLABORATIVE PROCESS THROUGH INCLUSIVE ITERATION BRYAN BELL, NCSU DESIGN MATTERS KATHERINE PEELE, LS3P IMPACT OF COVID-19 IN RUAL AREAS MARC MARCHANT, LS3P THE CRISIS IN RURAL HEALTH CARE WILLY SCHLEIN , LS3P

RESPONSE CASE STUDY: PENDER COUNTY 14 PENDER COUNTY DEMOGRAPHICS CHRIS BONEY 15 PENDER COUNTY MEMORIAL HOSPITALS, AN ASSET IN TRANSITION CHRIS BONEY & MARC MARCHANT STAKEHOLDERS’ PERSPECTIVES 18 18 18 19 19

NICK J. GALVEZ MBA, RURAL HOSPITAL MANAGER, OFFICE OF RURAL HEALTH, NC DEPARTMENT OF HEALTH AND HUMAN SERVICES SUSAN BULLERS PENDER COUNTY RESIDENT RUTH A. GLASER FACHE, PRESIDENT, PENDER MEMORIAL HOSPITAL ANGELA LIVINGOOD PHARMD, MHA, BCGP, PHARMACY MANAGER, REGULATORY COMPLIANCE, PENDER MEMORIAL MICHAEL COLE PRINCIPAL, COLE JENEST & STONE, LANDSCAPE ARCHITECT

WHAT ARE CREATIVE DESIGN RESPONSES? 22 26 30 34 38 42 46 50 54 58 62 66 70 74 78 82 86 90 94 98 102

PENDER COUNTY HEALTH + RESILIENCY PARK LAUREN WICK ROCKY POINT COMMUNITY HEALTH CENTER BROOKE CREDLE HAMPSTEAD WOMEN & CHILDREN’S CENTER BINGHUI LYU PEDIATRIC & CHILDCARE COMMUNITY CENTER NIGEL BARBER PENDER COUNTY HOLISTIC CARE RACHAEL HAAS NEW HANOVER REGIONAL COMMUNITY HEALTH & WELLNESS CENTER CARLOS TORRES-CERVANTES DIAGNOSTIC OUTPOST & WELLNESS CENTER BRENNA MCQUAY PENDER FIREHOUSE CLINICS MARA LOWRY SURF CITY COMMUNITY CENTER SYDNEY SHOFFNER HAMPSTEAD FOOD HUB MARYLU BARTOLON PUAC ROCKY POINT NEXUS CENTER CORBIN BAREFOOT ROCKY POINT HEALTH & WELLNESS EDUCATION CENTER JASMYN BYRD CURRIE COMMUNITY ACTIVITY CENTER CAROLINE ANDERSON ROCKY POINT MENTAL HEALTH & WELLNESS CENTER ARIEL HILLS SAFE SPACES FOR MIND, BODY, SPIRIT KENDALL YOUNT ROCKY POINT WELLNESS & TREATMENT CENTER ABIGAIL UHRICH PENDER COUNTY OUTDOOR WELLNESS CENTER ANUSHA KHANSAHEB ROCKY POINT COMMUNITY CENTER DOTTIE SLOAN ROCKY POINT COMMUNITY HEALTH CENTER REBECCA CURRY THE HEALTH HABITAT: COMMUNITY CENTER + GARDEN GAYATRI GANESH PENDER MOBILE CLINICS & ROCKY POINT DOCKING HUB URMICA YELAVARTHY

RECOMMENDATIONS 108 LS3P REVIEW COMMENTS CHRIS BONEY, MARC MARCHANT & DANNY ADAMS 110 DESIGN REVIEW COMMENTS REVIEWERS: ESPY HARPER, DAN HARROP, DEAN RAINS & ELLISON LAUGHTON

THE COLLABORATIVE PROCESS THROUGH INCLUSIVE ITERATION BRYAN BELL, NCSU The Public Interest Design graduate architecture studio at NCSU’s College of Design explores methods of how design can address the critical issues faced by communities. Students are engaged in incubating a community-based project with the community. The assignments demonstrate how public interest design can enhance traditional design education and skills and how this emerging sector can be a meaningful part of professional practice. The design process is focused on a triple bottom line evaluation called the Social/Economic/Environmental Design (SEED) Evaluator which supports a holistic, creative approach to design driven by community needs. This means that we seek to address the multiple challenges identified by communities as goals of our design projects. In addition to finding needs for design, each student will find an appropriate site and write their own program. For the Fall 2019 studio, students learned about the on-going crisis in rural healthcare delivery taking place across the country. With reports that as many as 600 rural hospitals are vulnerable to closure in the United States, this crisis will continue to affect our rural populations. Lower incomes and higher rates of uninsured people in poor, rural areas (such as Eastern North Carolina) lead to higher levels of uncompensated care. And, lack of access to healthcare education contributes to unhealthy lifestyles and habits. Because healthcare delivery is such a complex topic, it was an advantage to involve industry professionals (such as hospital system administrators, healthcare architects and potentially, additional higher education institutions with a focus on public health) in panel discussions and final critiques of design solutions. Our primary partner is LS3P, the North Carolina AIA 2018 Firm of the Year. Two key local stakeholders are current local health care centers of Pender Memorial Hospital and New Hanover Memorial Hospital. Students were tasked with finding other stakeholders to give them feedback on their ideas. The students worked with these and other stakeholders and residents to understand the concerns and challenges of healthcare delivery, as well as other issues identified through their engagement process. Through a rapid iteration brainstorming process, called “asset-based design,” hundreds of good ideas will be identified through a team

selection process and will be combined as the project moves forward. Through this team method, well considered and resolved ideas will move forward. Final project evaluation will be gauged by project stakeholders and instructors, based on how well the design result addresses the established needs and meets the established “vision of success” through an inclusive and collaborative process. Each student design project is based on their research and engagement that identified a community and their local needs. The buildings activities (program) should relate directly to addressing these needs through the SEED process by answering the following questions:

These steps allowed the students to work in tandem with their community partners to uncover possible solutions that were evaluated from the perspective of social, economic and environmental impact. The desired outcome is that students applied their skills to a real challenge in a real community, gained a deeper understanding of the real-world challenges of healthcare delivery and design, and experienced a community engagement process.

Who is the COMMUNITY the designer intends to serve and what are the shared elements that define it as a community? What are the ISSUES that the designer found to be critical for stakeholders? The community? Who are the STAKEHOLDERS and what different interests do they represent? What other research was completed to present and confirm NEED? What are the community’s ASSETS & POETRY and how can they a play a role in the solution? How did they ENGAGE with some of these Stakeholders to develop concepts, and then ask them for verification or redirection of the conceptual design ideas? What is the VISION OF SUCCESS, (goals) for the design project (and possibly further forward)? How does the SITE SELECTION reinforce relationships and use available assets? What DESIGN SOLUTIONS house these activities and facilitate for these results? What ACTIVITIES/PROGRAM positively will impact the identified needs and achieve the vision of success? What is the specific square footage or SPATIAL ALLOCATION allocated for each activity? What PERFORMANCE MEASURES confirm that the outcome equals the vision of success?

DESIGN MATTERS KATHERINE PEELE, LS3P With our unique education in problem solving and design thinking, architects have the privilege and responsibility of deploying our skills in service to the greater good. We believe that design matters, and that the profession of architecture is vital to addressing the most pressing issues impacting our communities. Access to healthcare for all is a critical issue across the US. Disparities in access are most visible in rural populations, disproportionately affecting low income communities and communities of color. LS3P has deep roots in the Southeast, and healthcare design represents a significant portion of our practice; as such, we are committed to engaging with the communities in which we live and work to provide equitable, inclusive solutions that lead to better healthcare outcomes for all. In 2019, our firm developed a new vision statement which reaffirms our purpose and our process: “In our commitment to the Southeast, we create architecture that enriches community through a culture of design excellence, expertise, innovation, and collaborative engagement.” Out of this vision grew a renewed focus on design in service to the public interest, along with an internal Knowledge Team – Ignite- dedicated to innovation. The Rural Healthcare studio was one of Ignite’s earliest initiatives. We have long admired the work of Bryan Bell, Design Corps, and the Public Interest Design Institute; we also have strong ties with NC State University’s College of Design. Partnering with Bryan and NCSU for this studio in the fall of 2019 gave us the opportunity to do a “deep dive” into critical issues and potential solutions in our own backyard. The world has never needed design thinking more. We commend these students on their hard work and innovative thinking, and we look forward to seeing some of these ideas as they translate into the rural built environment. The emerging solutions from student explorations will have real-world impacts on our rural citizens and their communities, with potential applications for widespread use.

IMPACT OF COVID-19 IN RURAL AREAS MARC MARCHANT, LS3P Rural healthcare is facing huge challenges due to a confluence of economic, geographic, and social issues. These issues are increasingly limiting access to critical healthcare services across the continuum of care for rural populations. The rural healthscape is reflected in stark statistics, and each data point represents a very real problem for rural citizens and their families. Supply and demand is a significant challenge. The archetype of the old country doctor who made house calls, delivered babies, and knew everyone in the community has given way to community-based hospitals; these, in turn, have given way to an increasingly sparse network of providers. A recent study (link) indicated that less than 2% of soon to be medical school graduates are interested in living in communities of less than 25,000 people, and only 1% are targeting communities of less that 10,000. Staffing shortages in rural hospitals are an ongoing problem, along with declining numbers of physicians in private practice in rural areas. Beyond staffing issues, changes in hospital funding in recent years, including new models in reimbursement and shifts in care options, have made it extremely expensive to provide healthcare spanning the full range of needs in rural settings. Addressing community needs for everything from minor procedures to basic emergency and imaging services to acute issues requiring specialty care has become prohibitively expensive. It is not unusual for people living in rural areas to travel 200 miles to see a specialist for cancer treatments, chronic illnesses, or even trauma care. This travel burden often falls on those who are least able to afford it. Lack of access disproportionately impacts communities with a high percentage of low-or no-income individuals. Thriving agricultural or manufacturing economies used to sustain their small towns; as these industries have declined, many areas lost their ability to sustain the hospitals, clinics, and private practices that cared for their citizens. The merger/acquisition environment in healthcare presents another ever-changing and challenging issue. Much of the Investment in

physical capital is market-driven and has shifted to cities; this flight of care to urban centers has drained the healthcare resources of rural communities. The news is not all dire; many large healthcare systems are working to make investments in rural communities, and telemedicine offers huge potential to provide affordable, accessible care without requiring travel. However, each rural county may face its own unique healthcare challenges due to factors such as geography, nutrition, economic opportunities, and environmental conditions, and effective responses need to be rooted in a deep understanding of each community. Local, accessible, familiar healthcare options may be best suited to fostering trust and engagement with rural populations, and these options are increasingly limited.

THE CRISIS IN RURAL HEALTH CARE WILLY SCHLEIN, LS3P COVID-19 puts tremendous stress on rural America, where access to care is already strained due to many factors such as financial means, insurance coverage, language barriers, health literacy, preexisting health conditions, transportation costs, distance to care, limited technology, multi-generational housing, hospital and clinic closures, and stigmas associated with behavioral health and substance abuse treatment. Vocations in rural areas often require physical labor in close quarters where the use of masks, handwashing, and social distancing are difficult. All of these factors have a cascading effect on COVID-19 infection rates, according to the Rural Health Information Hub.

THE PEOPLE OF PENDER COUNTY CHRIS BONEY The history of Pender County mirrors the history of the rest of rural eastern North Carolina. Its history is that of tobacco and timber; over the years, its enduring rural values have been changed by twenty-first century considerations including racial divisions and poverty along with coastal development and economic expansion. Pender County was carved from the north woods of New Hanover County in 1875, envisioned as a place of potential growth along the railroad line. As a rural county it offered great agricultural potential and saw rapid expansion in early 20th century, and numerous homestead communities developed on what was cheap land at the time. Over the years, as tobacco has declined as an economic force, Pender County has trended toward coastal tourism which superseded agriculture in the late 20th century as a primary economic engine. This transition led to very sharp divisions into what is essentially two separate “counties” emerging; one is a thin strip of coastal prosperity, while the other is a deep pocket of rural poverty.

PENDER COUNTY MEMORIAL HOSPITALS, AN ASSET IN TRANSITION CHRIS BONEY & MARC MARCHANT In the mid-20th century, the Hill-Burton Act provided federal grants and loans which allowed many rural counties to invest in hospital infrastructure. These county-owned hospitals served their populations well for many years; however, the difficulties of maintaining and operating these facilities increased as rural populations begin to dwindle. As these hospitals became more difficult to sustain economically, counties began to consolidate their efforts and with shared healthcare facilities, which created new political and economic challenges in terms of equitable access. Pender Memorial Hospital opened in Burgaw, NC in 1951, and was among these rural hospitals made possible by the Hill-Burton Act. Its utility has declined over the decades to the point where it now struggles for identity and economic viability. Because of that, it has been slated for replacement or closure, leaving a potential gap for the rural poor in the county without means to travel to larger nearby hospitals.

Pender County’s current population is approximately 57,000, with densely populated and affluent tourist areas along the beaches and sparsely populated lower-income areas inland. The countywide poverty rate is 15.8%., with a median annual income of $49, 357. (link) Proximity to Camp LeJeune draws a strong military presence in the community; local points of pride include historic sites, familiar small-town businesses, an annual Blueberry Festival, and the natural beauty of the coastal landscape. It is into this framework that the NCSU studio immersed itself to help determine ways to provide better access to healthcare for a largely forgotten area of the rural South.

NICK J. GALVEZ MBA, RURAL HOSPITAL MANAGER, OFFICE OF RURAL HEALTH, NC DEPARTMENT OF HEALTH AND HUMAN SERVICES Small Rural Hospitals and CAHs are more financially vulnerable than larger hospital systems and are often the only medical facility in a rural community – if they close there will be reduced access to acute care and emergency room services. Recently, in early 2019, Washington County Hospital suspended their hospital services and emergency services for several months. ORH assists these rural hospitals to use their grant funds for projects in the following areas for improvement: Value Based Purchasing, Accountable Care Organization and Payment Bundling Activities. The Office of Rural Health’s Rural Hospital program focuses on 12 Small Rural Hospitals and 20 Critical Access Hospitals (CAHs). A CAH has a special designation from the Centers for Medicare and Medicaid Services (CMS). CAHs have 25 beds or fewer and receive cost-based reimbursement. Small Rural Hospitals have 49 available beds or fewer. ORH administers two federal grants on behalf of Small Rural Hospitals and CAHs to improve their viability, quality of services, and integration with the rest of the health care system. These grants are the Rural Hospital Flexibility Grant Program (FLEX) and the Small Rural Hospital Improvement Grant Program (SHIP), both of which receive recurring federal funding.

SUSAN BULLERS PENDER COUNTY RESIDENT I think the biggest need in Pender County is for universal internet access. The low population density in the rural western part of the county makes running cable too expensive to be profitable so residents are limited to satellite internet, which is slow, expensive, goes out in storms etc. It makes it difficult or impossible to use Zoom, send large files, or stream anything. This has serious impacts on the economic opportunity in this area, even more so these days with Covid. You cannot start a business, do homework, work from home, access health care, shop, etc. without decent internet.

RUTH A. GLASER FACHE, PRESEDENT, PENDER MEMORIAL HOSPITAL As you may be aware, over one year ago, New Hanover Regional Medical Center announced its intent to explore potential partnerships with larger health care systems. A few months ago the list was narrowed to three finalists – Atrium, Duke and Novant and then in the last couple of months the list was narrowed again to simply Novant. Over the next couple of months, NHRMC is working with them on due diligence, etc., and are hopeful the New Hanover County Commissioners will give another blessing of this partnership in mid-to late October of 2020. But as you know, Pender Memorial Hospital is simply a managed organization (owned by Pender County and managed by NHRMC). While we hope that we will ultimately come under the same ownership, that won’t even begin to be explored until and unless the NHRMC partnership deal is complete (which is a year or more away). And the decision will lie with the Pender County Commissioners. In the meantime, NHRMC has announced their intent to apply for a certificate of need to build a hospital on the campus of ED North (just a few hundred feet from the Pender County line). If you know anything about the traffic patterns in Pender County you know that this new hospital will serve southeastern Pender County (not the side of the county where our current Pender Memorial Hospital is located). The future of PMH is bright . . . but what will it be? We exist in a facility that was originally built in 1951 (and has now had 9+ additions). We exist in the middle of a residential neighborhood. While stormwater conditions have improved since you were last here, we still have issues of flooding in good “Burgaw Rain”. NHRMC has been very open about needing to do a replacement facility for PMH. But what shall that be? That is all yet to be decided.

ANGELA LIVINGOOD PHARMD, MHA, BCGP, PHARMACY MANAGER, REGULATORY COMPLIANCE, PENDER MEMORIAL HOSPITAL Pender Memorial Hospital is available to service the residents of western Pender County, the majority of the county’s landmass but the minority of the population. Additionally, Pender Memorial is a critical-access hospital limited to 25 patient beds in addition to our 39 skilled nursing facility beds. Our growth area is in short-term and long-term rehab and ambulatory care services. With the known intent of New Hanover Regional Medical Center to replace the current Pender Hospital facility at some point, how do we maintain excellent service in our current one in the interim? What can we do to make our relatively small footprint as attractive and multi-functional as possible? How do we convert traditional hospital spaces to ones more attractive to the rehabilitation population utilizing our physical therapy, occupational therapy, and speech therapy services? What would a rehab space look like for the future needs of our growing county and what other services like cardiac rehab or pulmonary rehab could be added? Finally, as COVID-19 has opened to us, how may telehealth be integrated with face-to-face care? Where the use of masks, handwashing, and social distancing are difficult. All of these factors have a cascading effect on COVID-19 infection rates, according to the Rural Health Information Hub (link). https://www.ruralhealthinfo.org/

MICHAEL COLE PRINCIPAL, COLE JENEST & STONE, LANDSCAPE ARCHITECT Pender County Geomorphology Bordering North Carolina’s expansive southern coastal plain, Pender County is the state’s fifth largest by area at 933 square miles. The landscape is dominated by flat, low-lying terrain with 115’ of elevation change extending from the northwestern ridges along I-40 to the Atlantic Ocean. The most prominent hydrologic features are the Cape Fear, Black and Northeast Cape Fear Rivers with well-drained short slopes, agriculturally rich soils, and immense biologically diverse swamps/wetlands (almost 7% of the county is water). The Angola Bay and Holly Shelter nature preserves comprise more than 11% of county land. Thick woodlands of towering pines and majestic hardwoods make up 80% of the county vegetation.

EXECUTIVE SUMMARY ISSUES IDENTIFIED & NEEDS ADDRESSED Pediatric Healthcare Community Placemaking Disaster Recovery, Training, Response Rehabilitation Center Mental Health Services Internet Access

The Pender County Health and Resiliency Park is a collection of flexible spaces aimed to work in cohesion to benefit the community, almost like a campus. The park includes a primary care center, rehabilitation center, community kitchen, market and farming, and a coworking/training space. Rather than proposing a stand-alone building, each multi-use facility is meant to not only support, but become integrated within the existing network of community services already available in the area. In the event of an emergency, each facility within this model is designed to adapt and serve as a disaster training, response, and recovery hub for the local community and other North Carolina residents evacuating the coast. The goal of the Health and Resiliency Park is to provide a sustainable, accessible model of healthcare delivery that will encourage community placemaking and continue to connect, educate, and adapt to the evolving needs of the growing population. In an effort to cultivate a space personal to Pender County, one of the main design objectives will be to celebrate the agricultural history of the area by having each building reflect the aesthetic of the tobacco barns native to rural North Carolina.

EXECUTIVE SUMMARY ISSUES IDENTIFIED & NEEDS ADDRESSED Community Center Emergency Management Disaster Preparedness + Recovery Long Term Healing Physical Therapy + Occupational Therapy

Surveys and interviews with residents of Rocky Point indicate the community lacks a clear center: respondents describe it as a place without centers of activity, and expressed greater affinity for Wilmington and the coast than their local context. Residents may be able to identify a geographic center, but few places to gather. My proposal addresses this with a self-sustaining community center that incorporates needed services in the area and acts as a nucleus for future growth. Supplementing the already-existing medical campus with long-term care and rehabilitation services can imbue the project with day-to-day function. In the aftermath of hurricanes endemic to the North Carolina coast, the building can shift to providing residents with critical services and counseling.

EXECUTIVE SUMMARY ISSUES IDENTIFIED & NEEDS ADDRESSED Childrens + Womens Center Community Center Prevention Services Shelter Disaster Recovery

This proposal is a community center serving women and children populations in Hampstead. The concept is to build a “Concourse for Healthcare”. Considering the current healthcare situation in Pender County such as specialty physician shortage for children and women, increased infant mortality and women’s weak health consciousness during pregnancy, this health center will provide general treatment and prevention services for women and children. To improve residents’ knowledge and awareness, series of training and education lectures would be held in the auditorium in normal times. But in response to the emergency situations during hurricane, this auditorium would be used as a shelter, and this center will also include emergency center which can be used for disaster recovery.

DAY TO DAY OPPERATION

DISASTER RECOVERY

EXECUTIVE SUMMARY ISSUES IDENTIFIED & NEEDS ADDRESSED Pediatric Childcare Community Center + Wifi Preventative Care Pharmacy

My building is a pediatric and childcare community center. My design will feature: a pharmacy open seven days a week, K-8 and sick childcare, coastally resilient construction, and a library with wifi. I plan to serve Pender County residents, specifically near K-8 schools in the Rocky Point region. The interests of these residents are under-represented with limited access to critical resources essential to raising a healthy family unit. I seek to serve growing families with need for childcare. I propose a healthcare facility that centrally locates the resources of pediatric healthcare, childcare, and pharmacy. Additionally, to ensure the resilience of these resources the design must be resilient to natural disasters.

Mental Health Substance Abuse Crisis Care Long Term Recovery Community Center Counseling Outdoor Recreation Classrooms + Wifi Hub Greenway

A mental healthcare center focused on holistic health practices through social and environmental connectivity Pender County Holistic Care places particular emphasis on mental welfare and substance abuse in Surf City and adjacent populations. The Pender County Health Assessment this year identified the community health needs priorities to be focused on mental health and substance use disorders. The need identified through this data was reinforced by a negative public opinion on existing methods of long-term mental healthcare in the area, and by a desire from the residents to strengthen the area’s sense of community to grow support systems. What I’m proposing is a center to facilitate connections in a fashion that is mutually beneficial to the community already active within the adjacent Parks and Recreation Center and those in healing at the Pender County Holistic Care by fostering social relationships. This is accomplished through a program which works on three levels; first is for those in need of crisis care with a small ER, second is for those in need of long term residential care for mental illness and substance abuse disorders in a residential unit, and third is for the continual use of the community with group and private counseling rooms, a public cafe, and classrooms for use by the Surf City Parks and Recreation Center’s growing community programs and classes.

EXECUTIVE SUMMARY ISSUES IDENTIFIED & NEEDS ADDRESSED

This Wellness Center will be an extension of New Hanover Regional and encourage preventive healthcare through physical activity.

Preventative Care Physical Activity (PT) Health Education Community Gathering Child Care Fitness

As the population of Rocky Point continues to increase, measures have to be taken to address the high rates of chronic illnesses brought upon by obesity and a lack of access to exercise opportunities in the area. As the township stands today, there is also a lack of spaces for the community to come together and celebrate its history and culture. My building looks to solve these issues by providing cardiac rehab, physical therapy, physical fitness opportunities, health education, and gathering spaces for the community. Located in the heart of Rocky Point’s commercial center, the center will come equipped with child care services, classroom spaces, a swimming pool, massage rooms, group fitness spaces, strength training equipment, rehabilitation equipment, and an indoor track. Outside of the building the landscape will be designed to contain outdoor yoga spaces, 1-mile walking trail, tennis and basketball courts, multipurpose fields, gardens, and pavilions.

EXECUTIVE SUMMARY ISSUES IDENTIFIED & NEEDS ADDRESSED Mobile Med Station Outpatient Diagnostic Outdoor Recreation Health + Wellness Education Fitness Wifi Hub

Diagnostic Outpost and Wellness Center is an “outposts” that creates a space for mobile outpatient/ diagnostics vehicles to station. It is located in Rocky Point, Pender County near the junction between three highways, I-40, US-117, and NC-210. This will provide as a main health station for vehicles to then branch out from to help other areas of Pender County. This project is for those in Pender County who have limited access to healthcare resources, either due to time or distance. These outposts will also be a part of a community system by implementing outdoor recreational space, as well as indoor health and wellness classes to help inform and encourage the public on wellness.

EXECUTIVE SUMMARY ISSUES IDENTIFIED & NEEDS ADDRESSED Trust First Responders Support Preventative Care Health Education Disaster Security Community Spaces Outreach Clinic

Pender Firehouse Clinics take a holistic, outreach-based approach to healthcare in Pender County, increasing preventative care and health education through a system of mobile outreach clinics hosted at fire stations. Pender County is currently experiencing significant growth, which is exacerbating the divisions between rural and coastal areas, a lack of trust and access to healthcare resources, and the need for disaster resilience. Firehouse clinics would provide preventative care and education throughout the county - increasing healthcare, disaster security, and community in a trusted setting: fire stations. To illustrate this concept, I am designing a prototype fire station, along with small clinic and community buildings that can be placed with existing stations. Located in Hampstead, the prototype would define a center for the growing Hampstead community, while introducing the county-wide system to build trust, health, resilience, and community throughout Pender County.

EXECUTIVE SUMMARY ISSUES IDENTIFIED & NEEDS ADDRESSED Surf City Community Center Wellness through recreation Support services for first responders Economic Tourism support

The facility is located next to the Surf City Fire Department as they will be the primary operators of the building. The building will be providing health services for free to the community of Pender County. It will be able to do this by generating revenue through high-end activities provided to the tourist population of Surf City, thereby supporting the economic base of the area. It will also provide spaces for first responders to allow them to relax and take a break from their stressful jobs.

POPULATION MAP

EXECUTIVE SUMMARY ISSUES IDENTIFIED & NEEDS ADDRESSED Food Insecurity Nutrition Knowledge Community Gathering Access to Healthy Food

Food plays an important part in the health of a community. Pender County provides diversity in the food that is produced through its area, from farming land to the coast land. Hampstead is the fastest growing part of the county with a population density of 85.7% and around 40% of the population being families. As a growing community, there is a need for this knowledge on nutrition. Currently there is a community partner, 4C’s Food Pantry, who has focused on providing food to the citizens of Hampstead since 1988. Working along with 4C’s in creating a ‘food hub’ will provide the community with the knowledge of nutrition and will also create a central location for the community to gather for recreational activities.

EXECUTIVE SUMMARY ISSUES IDENTIFIED & NEEDS ADDRESSED Community Center Community Placemaking Preventative Healthcare Rehabilitation Center Outdoor Recreation Internet Access

The Rocky Point Nexus Center is a collection of buildings and outdoor spaces aimed at fostering community and bringing the disparate elements of Rocky Point together. The center includes a community and administrative building, a classroom and kitchen building, an exercise facility with training spaces, and multiple open-air pavilions. While each building is designed for its specific purpose, the buildings are meant to incorporate many of the programs and services that are already available for the community but do not have a way to reach out. Multiple spaces have room to create or house new programs to accommodate any service needed. The Nexus Center seeks to provide accessibility for the community as well as to promote healthy living, exercise, education and community bonds for the residents of Rocky Point. One of the main design objectives is to open up the buildings both physically and visually by utilizing glass and adaptable spaces, allowing the building to change with the needs of the community.

EXECUTIVE SUMMARY ISSUES IDENTIFIED & NEEDS ADDRESSED Preventative Care Physical Activity (PT) Health Education Community Gathering Access to health Exercise Nutrition Community Center

The Rocky Point Health and Wellness Education Center is a space designed for the community to promote heaty eating and exercise habits, and detect and prevent conditions associated with food insecurity and fitness limitations. This center will include a program designed to interact with local schools for nutrition and physical education as well as serve as a health and nutrition hub for residents to spend time with one another and share a sense of community. The Health and Wellness Education Center is made up of three main buildings: the Health and Wellness Center, the Fitness and Physical Therapy Center, and the Community and Education Center. Each building provides spaces between them for a farmers market and exterior community space users can feel open and welcoming to the community.

EXECUTIVE SUMMARY ISSUES IDENTIFIED & NEEDS ADDRESSED Fitness And Recreation Wifi Access Disaster Recovery Access To Healthy Foods Preventative Medical Care Interpersonal Engagement / Isolation Economic Growth Professional Development Opportunities - Youth Activities Substance Abuse Support Groups

The Currie Community Activity Center is a recreation and education facility in western Pender County. The vision for this facility has grown out of an almost ten-year endeavor to bring a community center to Currie. Started by the Greater Currie Community Action Group in partnership with the Moore’s Creek Missionary Baptist Church, the vision of success for this project is a multi-use facility that fulfills the intersecting needs for wifi access, interpersonal engagement, recreational space, healthy foods, professional development opportunities, youth activities, medical care, and economic development. This facility would be equipped to transform from every-day function to fulfill acute needs such as housing, food and water distribution, and access to tornado and flood-safe rooms during disasters. Through a partnership with this trusted local group, it would be possible to address community challenges such as food insecurity, obesity, limited educational and professional opportunities, mental health challenges associated with isolation, and disaster recovery while providing enriching opportunities to all the people of Currie and western Pender County.

EXECUTIVE SUMMARY ISSUES IDENTIFIED & NEEDS ADDRESSED Mental Health Services Substance Abuse Services Social Services WiFi Access Public Space Educational Safety Classes

The Rocky Point Mental Health and Wellness Center is a multi-use mental health facility that aids not only the community of Rocky Point, but also Pender County as a whole. Located in a rural area where household income is low and travel distances to services may be long, this facility aims to act as a building of resources for residents. This facility is a direct response to the residents’ expressed need for counseling resources at a closer distance, and for an easier experience requesting social services. Target groups served would be veterans, low-income residents, and residents with poor mental health and substance abuse issues. Whether it is a need for mental health resources or social service resources, visitors can get the help they need all in one place. Through the use of flexible office spaces and 1-on1 meeting rooms, the project serves mental health, social service, and telehealth functions. The adjacent library, café space, and lush gardens serve as places of socialization, where members of the community can get out with their families and interact with one another to diminish the isolation that may be a prime contributor to poor mental health of the area. The project goal is that this facility will foster wellbeing and a more well-rounded, healthier community.

EXECUTIVE SUMMARY ISSUES IDENTIFIED & NEEDS ADDRESSED Safe Spaces For A Variety Of Activities Needed In The Underserved Communities Of Pender County Support For Those Suffering From Addiction And Feelings Of Isolation Adequate Mental Healthcare Access To Recreational Services To Encourage An Overall Stronger, Healthier Community

Pender County is made up of a collection of disproportionally supported communities in need of connectivity. Rocky Point is one of these communities that requires infrastructure that can effectively address the lack of access to adequate mental health care and the inability to participate in positive recreational activities. By creating a new source for community through combining access to mental healthcare with recreational programs and space, users should be able to access preventative care for their Mind, Body, and Spirit in a visible and inclusive community building. Creating a comfortable, trustworthy environment can reinforce the facility’s potential for serving the community when faced with natural disaster. The supportive, reliable nature of the place should become a symbol of strength and resilience for the people of Rocky Point and the greater Pender County when tackling their vulnerability to hurricanes and flooding.

EXECUTIVE SUMMARY ISSUES IDENTIFIED & NEEDS ADDRESSED Substance Abuse & Mental Health Treatment Improved Nutrition Access to Exercise Community Connections

The Rocky Point Health and Wellness Center is designed to provide the residents of Rocky Point an opportunity for connection, healing, and community. The center consists of two wings: a wellness wing and a mental health and substance support wing that are connected by a bridge. The wellness wing houses a commercial kitchen for community meals, an open dining space, and an exercise space with expansive views of the landscape. The support wing includes exam rooms, group and individual counseling for various therapy modalities, telehealth, and a 24hr pharmacy. The two programs are meant to work together to foster health and wellbeing in a holistic manner. The site itself promotes peace and healing with plenty of walking trails as well as gardens for viewing and harvesting produce. A generous outdoor area, enclosed by trees, can be used for event space and general recreation. The concept relies heavily on nature being a necessary part of the healing process.

EXECUTIVE SUMMARY ISSUES IDENTIFIED & NEEDS ADDRESSED Lack Of Health Facilities Distrust Of Health Facilities Health Issues: Drug Abuse, Alcohol Abuse, Obesity, Unhealthy Eating Habits, Mental Health Problems, Feelings Of Isolation, Lack Of Exercise Access To Wifi For Education And Telehealth Lack Of Outdoor Recreation Spaces Prone To Flooding ; Lack Of Disaster Relief

In order to combat some of the prevalent issues such as poor healthcare, lack of outdoor space, lack of wifi, and poor disaster relief in the rural part of Pender County, a proposed Pender County Outdoor Wellness Center is required to help mend the county and create a sense of community. Through the Pender County Outdoor Wellness Center the citizens of Rocky Point and Pender County will gain access to outdoor recreation spaces, wifi and educational resources, a community gathering space, and a preventive health center. The Pender County Outdoor Wellness Center will also attract tourists and revenue from the coast and reconnect the rural western part of Pender County. In times of emergency this center will serve as a place of relief and assistance to the community. The trails and outposts system along with the Welcome Center will reconnect the entire county while also showcasing the natural beauty and historical significance of the county. Through the Pender County Outdoor Wellness Center, Rocky Point will no longer be a stop along the highway but instead a destination. Overall, the Pender County Outdoor Wellness Center creates a sense of place for the people of this area and gives them a place where they can create a community.

EXECUTIVE SUMMARY ISSUES IDENTIFIED & NEEDS ADDRESSED Education Opportunities For Gardening “One Stop Shop” To Purchase Basic Foods, Exercise, Do Work, Or Fill A Prescription Daycare For Those Who Need It

Rural areas in North Carolina, like Rocky Point in Pender County, face multiple setbacks such as higher poverty rates, food insecurity, no adequate place to exercise, and no place that marks a central location in town for residents. Rocky Point is in need of a central location to fulfill these everyday needs, while also being a place of community for the surrounding area. This community center will provide a 24 hour pharmacy adjacent to a mini mart, a workspace with free wifi, an exercise facility, outdoor walking trails, a daycare, community gardens, and a multipurpose room for people to have meetings or hold other educational opportunities. This center has the potential to partner with Rocky Point Pavilion Pharmacy and Sonny Rowe Farmers Market, as this can be the new location or expansion of each of these nearby establishments. Not only will this be an area that can hold potential future expansion of establishments, but it also blends together the benefits of being near town, while maintaining its rural quality. This will help to address some needs of the community while also being reminiscent of a town center, benefitting members of the community and surrounding areas. This project aims to serve as many members of Rocky Point and the surrounding area as possible. As there are several facilities on the property serving different needs, this center brings people together, creating a sense of community and unity that otherwise might be hard for some to find and achieve in a rural town like Rocky Point. My site is a “one stop shop” for fulfilling basic everyday tasks and needs, making this community center a place for people to spend as much or little time as they want here, as it caters to both important tasks and leisure.

EXECUTIVE SUMMARY ISSUES IDENTIFIED & NEEDS ADDRESSED Limited Access To Preventative Health Care + Education Resources Lack Of Specialists, Mental Health Services, And Disaster Preparedness Lack Of Preventative Resources To Better Educate The Community On Health And Wellness Care Lack Of Transportation And Resources To Create Community Ties And Ensure Trust, Health, And Resiliency Disaster Resilience Emergency Preparedness

Rocky Point Community Health Center is a collection of multi-use spaces aimed to work together to promote overall health + wellness through preventative care measures to create trust, health, resiliency within the community of Pender County. The Community Health Center is designed to work in unison with the existing medical campus to respond to the needs of specialists and mental health services in the area while being a destination for mobile medical clinics to dock. The community aspects of the design create accessible resources such as a community kitchen for nutritional education, safe spaces for outdoor recreation + gathering, WiFi access, and youth programs. In the event of an emergency, the buildings are designed to adapt and serve as a disaster recovery hub for first responders and the community. The facility’s partnership with PAS-TRANS, a public transportation service, will better connect the unincorporated parts of Pender County by providing locals with equal access to transportation allowing them to be connected to medial services and the community.

EXECUTIVE SUMMARY ISSUES IDENTIFIED & NEEDS ADDRESSED Therapeutic Mental Health Services Community Placemaking and Engagement Internet Access Food Stability Nutrition and Lifestyle Knowledge

The Health Habitat is a conglomeration of flexible spaces intending to address mental health and substance abuse issues among Rocky Point community members. The facility houses proximal access to healthy lifestyle knowledge and food stability, community engagement, lectures and activities, therapeutic healthcare, internet access, and disaster preparedness knowledge. The goal of The Health Habitat is to provide an accessible means of healthcare that will stimulate community togetherness and continue to connect, educate, and engage Rocky Point residents. In assimilating Pender County, the design concept centers around rural rich agriculture by having pine tree alleys and columns guiding the path and representing boundaries. The reflectivity of the alucobond cladding helps the building ground into the environment and further its poetic connection to nature, almost camouflaging into the landscape. The garden is integral to the project, as it is not only the centerpiece but is also indicative of the facility’s horticulture therapy. The diversity of the project will provide an access to essential resources which will strengthen community prosperity and wellbeing. A recreational space and healthcare facility that leverages existing local Pender resources will create a multi-functional and socially conscious comfort zone for community members.

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EXECUTIVE SUMMARY ISSUES IDENTIFIED & NEEDS ADDRESSED Access To Health Services Preventive Care Across County Hurricane - Disaster Response Unemployment - Part Time And Full Time Jobs Poverty - Access To Community Resources Transportation - Mobile Health Clinics In Communities

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By synthesizing primary, secondary, and focus group data, it became evident that the top 4 challenges of Pender County are access to health care, unemployment, poverty, and transportation. The aim of the project is to introduce a network of mobile health clinics across Pender County to bring preventive care directly into the rural and coastal communities. The Pender Mobile Health Clinic is a model for a “hospital on wheels” that is equipped with high-tech preventive health care resources including prenatal care, cancer care, cerebrovascular, and cardiovascular care. The MHC’s are positioned at the local EMS & fire stations. With a highly resilient design, these flexible units can function as rescue vehicles during a disaster. The docking station at Rocky Point will restock supplies into the MHC’s and maintain the vehicles. The site also serves as a “disaster shelter” during a catastrophe.

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LS3P REVIEW COMMENTS CHRIS BONEY As designers, our first step in crafting an intelligent response is to understand the underlying socioeconomic issues that have framed the problem. Diving deep into underlying community issues of Pender County, we can begin to understand how lack of access to healthcare has contributed to and compounded issues of poverty and socioeconomic disparity. Once we have a deep knowledge of these issues, we can begin to craft creative responses that lie outside of the traditional thinking that has helped to create the problem itself.

MARC MARCHANT

Healthcare design must address the holistic needs of a community; this is particularly important in rural counties. The three major factors that affect a county are health, education, and financial stability. How can rural hospitals extend beyond physical needs to be come a community center with resources for education, wellness, preventative care, and a stronger social network? In expanding our vision for rural healthcare facilities, we create the opportunity to identify and treat health issues early, when interventions can be more effective and less invasive. Through community education and better access to preventative care, we can address a full spectrum of issues such a opiod use, prenatal care, early signs of dementia, even financial planning. Facilities can include wellness centers which welcome the community and encourage physical fitness, rehab centers for people recovering from surgeries or cardiac events, classrooms, demonstration kitchens, and even cafeterias open to the local community as a welcoming gathering spot.

acuity-adaptable beds which can accommodate multiple functions can meet these needs through flexibility and adaptability. We can also design to accommodate mobile modalities such as trailered MRIs and mobile radiology suites to provide access to medical technologies without adding substantial infrastructure expenses. Likewise, healthcare facilities with integrated clinical components allow rotating specialists to occupy shared spaces for better access for the community and efficiency for the providers.

DANNY ADAMS Healthcare design for rural communities should be adaptable, scalable, and flexible. The facilities needs of a one-stoplight town may be very different from the needs of a town of 15,000 people; however, even a small facility must still be able to accommodate the full range of issues from acute care to chronic disease management to community wellness. In order to be effective, designs for rural healthcare must focus on local responsiveness. Each facility must not only target ease of access in emergencies, but also be appropriate for its unique place in terms of architectural character to reinforce familiarity, trustworthiness, and relatability. Functional appropriateness is also critical in allowing a facility to perform in inclement weather. Resilience accommodations include designing and detailing for extreme conditions such as hurricanes, droughts, flooding, high winds, or other unforeseen emergencies; this is particularly true in our coastal communities.

One of the best things design can do for rural healthcare facilities is to make them flexible and adaptable, and to accommodate the need for a holistic approach to health. A small community might not be able to afford a dedicated space for each function such as pediatric treatment rooms, labor and delivery rooms, step-down ICUs, medical/surgical suites, and every other specialty found in a large hospital; however,

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DESIGN REVIEW COMMENTS REVIEWERS: ESPY HARPER, DAN HARROP, DEAN RAINS & ELLISON LAUGHTON As reviewers for the Rural Healthcare studio, we had the privilege of watching these projects develop over the course of a semester, from informal desk crits to intermediate presentations to the final design review. The students engaged deeply with the complex issues surrounding rural healthcare, and conducted in-depth research and interviews to gather the data needed to help guide their designs. The resulting design interventions illustrate the students’ depth of thinking, optimism, and compassion. Though the projects were diverse in both function and expression, important common threads emerged as critical success factors for delivering healthcare services to rural populations.

FLEXIBILITY

Recognizing that rural counties have limited resources and that each healthcare facility must serve evolving needs, many projects focused on flexible spaces designed to adapt easily to changes in function. This “Swiss army knife” approach allows a clinical space to accommodate a range of rotating specialists, or a community market to pivot to emergency meals in the wake of a disaster. A site which provides community walking trails in fair weather can also provide infrastructure to host temporary shelters after a hurricane, and a structure which supports mobile medical equipment can transition to a deployment site for emergency crews or vaccination teams. Other projects imagined flexibility in terms of size, with scalable, modular elements that can expand along with community needs. Facilities which support multiple modalities will best serve their populations in the long run and, particularly in coastal areas, resilient design will be vital to maintaining services in an emergency.

SPECIFICITY Rural communities have commonalities in terms of economics, demographics, and limited healthcare access; however, each community is unique in its culture and character. Providing effective solutions begins with listening to and engaging with stakeholders. It

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is only by developing a deep understanding of a place that we can uncover needs and root causes of issues that are not immediately visible from data. The range of projects reflects the students’ authentic engagements with their stakeholders. Projects all shared the same goal- better healthcare for rural populations- but the designs provide solutions to community-specific barriers to healthcare access. Woven into these projects are strategies to address issues such as food insecurity, lack of daycare access for sick children, scarcity of beds for mental health and substance abuse treatment, and widespread mistrust of large institutions. Identifying these needs is the first step in developing solutions.

The students recognized the need to build trust with a building’s stakeholders through human-scale designs that speak to their experience. Elements such as gable roofs, open porch structures, and prominent use of wood found, in many cases, a modernist interpretation which feels timeless and rooted in its place.

PLACEMAKING Another recurring theme across the studio work is the need for community gathering spaces. In sparsely populated areas with limited resources, parking lots or gas stations may be the only places where people regularly experience the kind of informal, spontaneous social interactions that build authentic connections. As an alternative, many of the student projects envision community nodes and gathering places embedded into the campus. Welcoming, place-based solutions help to encourage community use and break down barriers to visiting a healthcare campus. To make these facilities a destination in addition to a place to seek healthcare services, some projects included dedicated community spaces such as conference facilities, classrooms, festival bandshells, markets, and demonstration kitchens; others created sites which engage communities with walking trails, fitness amenities, and wetlands views. Courtyards, interstitial spaces, and indoor/outdoor spaces provide varying levels of privacy and opportunities for interaction for visitors and staff.

FAMILIARITY Finally, many studio designs prioritized familiarity through warm, human scale elements referencing the vernacular architecture of barns, train stations, fire stations, and other common local forms.

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Designing for Rural Health Lesssons from Pender County Public Interest Design Studio Fall 2019 & 2020 With LS3P and NC State University, College of Design