J. Mark Smith, MBA, Assoc. AIA Vice President Easter and Mason Healthcare Consulting Corporation Nashville, Tennessee

This article addresses three case studies that outline the changes occurring within the small and rural hospital community. these changes represent "business driven" planning decisions that were based on both financial and asset related planning scenarios. Salient factors outlined in the article include:

1.	Current trends in type of care indicate growth in outpatient care relative to traditional care.
2.	There is a shift in the level and variety of care for the elderly and long term disabled, including a "continuum of care" to meet various levels of need.
3.	The major emphasis of healthcare dynamics is now cost-drive, and is the primary basis for healthcare organization's responses to managed care potential government cutbacks of Medicare and Medicaid.
4.	Demographics are changing. Expectations are rising. Consumers are more educated and "choosy."
5.	Short stay and Outpatient Clinics are expected to be as sophisticated and thorough as the former longer stays of traditional medicine. The trend is toward the advanced, high technology Outpatient Clinic, including the specialty clinic, such as cancer centers.
6.	Cost and functional requirements drive facility solutions. Facility changes are often the last resort in the mix of solutions to the problems of shrinking market share, reduced patient and indemnified revenues, and rising costs.

The article identifies and interactive and consensus building process with the full team of planners, architects and owners making business decisions based on the return on investment (ROI) factors. In addition, creative facility planning uses existing assets wisely, renovates remote facilities converted from other functions and offers suggestions for downscaling and demolishing existing obsolete buildings. Many of the smaller facilities have outlived their useful lives. The case studies include quotes from interviews with the clients who discuss the pros/cons of their planning and design process.

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