W. H. (Tib) Tusler, Jr., FAIA
Planning for Health
Kentfield, California

At a health care conference recently, I heard two things: first, that the "bed is dead," and second, that hospitals are not sure whether they are supposed to "heal or deal." While these statements may seem exaggerated, the bed is certainly taking second fiddle to ambulatory care, home care, and a variety of subacute modalities. Certainly the health care providers we work with are dealing as well as healing. I trust that the healing part still occupies most of their time.

We are currently in the midst of two trends that strongly influence our behavior and future planning in the health care field. The first is the intense, relentless economic pressure of managed care. The second is the freedom from the hospital bed that new technologies have given us.

An evolutionary leap is occurring in health care delivery. I believe we are undergoing a change that is a once-in-a-century event; that we have an opportunity to respond to the forces and freedoms offered by the current situation and use them as stepping stones to a community-based model of care. As radical as the current changes seem, they could and should become an incremental step toward a new model of health care delivery, one that provides comprehensive, effective, and cost-efficient care to communities.

In this century, there have been two periods when the acute care (bed-centered) model of health care was not the predominate one promoted for health care delivery. During the early 1900s and again in the 1930s there was a strong for a community-based model of care, in which the hospital is one cog in an integrated health care system, not its central focus. Planning, funding, and measurement of success are judged on community terms. Unfortunately, the movements toward this model were thwarted by the medical establishment. The first time it was the dominance of medical schools combined with the success in World War I of intensive trauma medicine that served to sideline a community-based system. In the 1930s it was the American Medical Association's reaction against "socialized medicine."

Abstract

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