Abstract
The HealthCite integrated health precinct is a new multi-purpose health, community, aged care and affordable housing precinct in southeast Melbourne, Australia. The health precinct, being developed by Guildfords Funds Management, supports a global trend towards integrated care models. Consumers expect these efficiencies to occur as healthcare costs keep rising and emphasis is placed on the consolidation of traditionally fragmented sectors, such as primary health clinics, allied health centres, specialist medical centres, day hospitals and community care programmes.

The two-stage development of the precinct (Stage 1: Private hospital and day surgery; Stage 2: Medi-hotel, community health, aged care and healing forest) is suited to smaller vertically integrated land sites, so HealthCite can be efficiently replicated in regions where space is a premium. HealthCite is based in Cardinia Shire on a at 10 hectare site to exemplify the major design benefits of medical facilities that possess infrastructure capable of delivering state-of-the-art clinical and community service care.

The healing forest in HealthCite Cardinia forms the conceptual framework for the precinct masterplan. We focus on ecology first, designing infrastructure to feed water and nutrients into landscaped communal services. This land area contains a number of functional spaces, including therapeutic, relaxation, active play, and food production services. These are designed to support inhabitants’ wellbeing, while seeking to retain all the attributes of self-sufficiency and sustainability in design and resources.

By offering differential services, HealthCite has the opportunity to expand beyond the catchment area. An important aspect of the expansion is the association with public hospitals and GP clinics throughout the region. As such, HealthCite can become a hub for prevention of unnecessary disease and treatments, while offering efficiencies in providing localised therapeutic treatment.

To maintain this level of design and planning for a hospital, a large degree of flexibility must be factored in. HealthCite also considers aspects of smart and effective design, such as interconnectivity and interaction between buildings and traffic/people flow.

The surrounding residential development will provide affordable housing for employees in the precinct and community. Co location of retirement villages and apartments within the vicinity of HealthCite provides a framework for an easier and less anxious transition to various housing options as people progress through the age cycle. 
 

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The Australian healthcare system is advanced in quality, access and efficiency1 but is facing the challenges of a growing population, greater prevalence of chronic diseases, and an increase in the number of older people as a proportion of the total population (figure 1).^1,2 Hospitalisations rose 3.7 per cent a year between 2004 and 2014; and 93 per cent of the average number of acute care hospitalisations occurred at private hospitals.² In 2014, the annual increase in hospitalisations outstripped the population growth rate of 1.5 per cent a year over the period 2004–14, suggesting pressure to bear on health services in the future.³

Another factor affecting Australian health is the trend towards greater efficiency in service provision. This is illustrated by the average length of stay having decreased from 3.4 to 2.9 days between 2004 and 2014,² and primary health services moving closer to the home or within institutional settings.

With a growing and ageing population, and increased co-morbidity of chronic diseases, the need for consolidated health services to meet future demand is becoming increasingly important. 

Australia is a fast-growing OECD country with growth of 1.6 per cent a year as of December 2016.^4,5 In addition to supporting the multidisciplinary care needs of older people, greater use of emergency department (ED) resources and health facility planning is foreseen, primarily because ED service demand is projected to outstrip population growth.^6,7,8

The three most prevalent chronic diseases in Australia are diabetes, cardiovascular disease (CVD) and chronic kidney disease (CKD). Twenty-nine per cent of Australian adults were diagnosed with diabetes, CVD or CKD in 2011–12, based on self-reported and measured data. Five per cent of Australians have diabetes,⁹ and 29.2 per cent of Australians aged 75 years and over have heart disease – the highest rate occurring in men aged 85 years and over (47.1 per cent).¹⁰ Ngu et al¹¹ estimate the prevalence of CKD in Australia to be between 11 and 14 per cent. Between 2014 and 2015, 1.7 million hospitalisations occurred because of CKD. In addition, the Australian Institute of Health and Welfare (AIHW)⁹ projects an 80-per-cent increase in CKD incidences by 2020. 

At least 7 per cent of Australian adults have experienced two of the three above-mentioned conditions, while 1 per cent of adults have experienced all three conditions.⁹ The presence of co-morbidity increases with age, particularly where one of the conditions is CVD. For example, those aged 65 and over who have both CVD and CKD are seven times more prone to these diseases than those aged between 45 and 64 (figure 2). 

Individually and collectively, diabetes, CVD and CKD are positively correlated with an ageing population. People aged 45–64 are four to ten times more likely to have a combination of co-morbidity than those aged 18–44. In addition, 4.5 per cent of those aged 65 and over have experienced all three diseases, while 22.4 per cent of the same group exhibited a combination of two of the three diseases (figure 3).

Healthcare industry trends 
 As a sector, healthcare is growing at 4.2 per cent a year in Australia, well above the services sector’s rate of 3.4 per cent.¹² Improved Australian living standards have resulted in increases in life expectancy and in the proportion of the older demographic.¹³ 

As Australia’s population continues to age and grow, new models of care are being designed to alleviate the increased pressure on health services. Hospital in the Home (HITH) has been effective in acting as an alternative to hospital care, reducing pressure on hospital beds and costs associated with acute care.^14,15 It has, however, presented new challenges, such as travelling between patients, leading to greater costs and time loss.¹⁶ 

HealthCite will provide an integrated range of world-class health facilities combined with IT connectivity spanning private hospital, day surgery, obstetrics and childcare, all co-located in the single precinct to serve a rapidly growing urban area. The precinct model can be replicated in other areas and represents the next logical step in the evolution of health. 

HealthCite 
Increased demand for hospital services has created a significant burden for Victoria’s acute healthcare providers, particularly in regional growth areas.¹⁷ As such, HealthCite is a long-term strategy to meet the growing communities’ need for multi-faceted healthcare services through a replicable health precinct.

HealthCite will act as the intermediary between practitioners, policymakers and financiers to develop the framework necessary to create social infrastructure for healthier communities in these regional growth areas. The practitioners include architects, urban planners, healthcare operators and construction firms. The policymakers include local, state and federal government. The financiers are those who control the flow of capital to the development of the project.¹⁸ 

HealthCite Cardinia
HealthCite Cardinia is a 10-hectare site located in the Cardinia Shire, south-east of Melbourne, Australia. Its objective is to deliver a continuum of health services across all ages in a shire whose population is expected to grow 89.36 per cent from 2016 to 2036 (figure 4). Over the timeframe reviewed, the greatest change in age as a percentage of total population in Cardinia will be the group aged 65 years and over. In addition, the number of people over 65 is projected to increase from 15.4 per cent of the demographic to 17.5 per cent in 2026, and to 18.3 per cent in 2036.¹⁹ The integrated health precinct will consist of: a 190-bed general surgical hospital (including an ED); 122-bed day surgery; aged care facility; medi-hotel; community health centre; childcare facilities; and three hectares of parklands featuring a healing forest and community garden (figure 5).

The interconnected network of health facilities in the HealthCite precinct aims to: promote greater co-ordination of care; and create economic and social benefits for the community.

HealthCite Cardinia aims to create economic and social benefits by locating next to an activity centre, key-worker housing, and two main arterial roads, which will provide easy access from all directions for emergency services. A study conducted by MacroPlan Dimasi²⁰ found that during the construction phase, HealthCite Cardinia will generate 1627 full-time equivalents (FTE) jobs and a further 2884 FTE jobs for daily operations. The development of HealthCite Cardinia will create higher-skilled job opportunities, while the key-worker housing to be developed in conjunction with HealthCite will aim to reduce medical staff and nurse attrition rates from the Victorian state average of 34.2 per cent.²¹

In addition, HealthCite aims to meet the social needs of the community by providing activity spaces and social infrastructure to promote health across all ages in each area in which it’s replicated. HealthCite Cardinia will also seek to connect the inhabitants of the precinct to the natural environments that surround them. It’s essential that the design and planning of the precinct is in line with the concerns of individuals and families at different stages of the housing life cycle (figure 6). 

Three pillars: sustainability, self-sufficiency and wellness promotion
HealthCite is intended to convey an acute awareness of the interconnected relationship between place and health to influence its design, construction and policy. HealthCite Cardinia is concurrently addressing the population and disease pressures in the healthcare system and delivering a precinct built on the three pillars of sustainability, self-sufficiency and wellness promotion.

Using evidence-based design (EBD) and processes for ecological responsibility, the precinct intends to deliver environmental, physical, psychological and economic sustainability, self-sufficiency and wellness. These factors contribute to the three pillars for all stakeholders and the surrounding community.

Sustainability 
Sustainability is defined by the World Commission on Environment and Development (WCED) as meeting the needs of the present without compromising the ability of future generations to meet their own needs.²² The objective of HealthCite Cardinia is to incorporate this definition into the built environment, using energy efficiencies and other aspects of sustainable building practices.  

Designing for sustainable practices and policies 
HealthCite Cardinia aims to have an operational culture that promotes sustainability. This may incorporate energy-saving practices such as the TLC intervention – an effective mechanism to achieve energy savings and carbon reduction. This concept is outlined below:

• turn off machines (T);
• lights out when they’re not needed (L); and 
• close doors when possible (C).

Research has proven that TLC has increased work efficiency, lowered costs and reduced carbon and energy consumption.²³ 

Sustainability indicators 
Key sustainability indicators defined by Guenther et al were considered in the design of HealthCite Cardinia and categorised into six major areas: site planning; form and facade; water; energy; construction practices; and community.²⁴

During the design process, the site on which the precinct is built needs to adhere to the local council’s approach to sustainability: namely, to balance the needs of the growing population with the preservation of Cardinia Shire’s environmental characteristics.¹⁹ In other words, HealthCite Cardinia focuses on forming a connection to nature. Site planning therefore focuses on providing all facilities with views of the central healing forest. Other likely benefits include: enhanced recovery from surgery; decreased heart rate; lower systolic and diastolic blood pressure; and reduced adrenaline noradrenaline and cortisol levels.^25,26 Evidence shows that natural scenery can elicit positive emotions in individuals, altering one’s mood or preference.²⁷ In addition, the site has been planned for sustainable internal and external travel. 

Form and facade have influenced the design of the hospital and its ancillary health facilities in the precinct. The hospital has rooftop gardens, which afford a visual appeal to patients and staff, while the green roof will also provide rainwater harvesting systems.  

HealthCite Cardinia recognises the link between lifecycle design (LCD) and sustainability, in which buildings engage in their environments through lifecycle events. These lifecycle events incorporate interaction between water, energy, food, air and materials.²⁸ HealthCite has incorporated LCD principles into the water resource flows, whereby it evaluates and applies the transport, process, use and reuse of water. HealthCite Cardinia will harvest storm/rainwater to be reused for toilet flushing, bed-pan maceration, commercial laundry, heat rejection systems, and landscape irrigation for the healing forest and an onsite treatment plant (figure 7).  

HealthCite Cardinia will have a central energy plant and integrated services building to provide services throughout the health precinct site. In addition, all health facilities will benefit from natural ventilation systems, designed for the Australian climate. To maintain sustainability and awareness throughout the precinct, there will be energy displays for all residents and staff to view energy use. Furthermore, buildings in the precinct will have onsite electricity generation via roof-mounted solar systems with central battery storage to support electric-transport charging stations. 

Owing to HealthCite Cardinia’s proximity to two main arterial roads, a sustainable sound strategy is required to minimise external noises for better patient care and an improved staffing environment. HealthCite Cardinia will employ acoustic-absorbing materials, construction practices and designs to limit noise pollution. 

To create a sustainable community, HealthCite Cardinia has prioritised food production. The healing forest will have a community garden, which will also incorporate self-sustaining processes such as aquaponics. Community gardens will be fertilised by organic waste produced by the hospital. Compost, which is degraded organic matter under controlled aerobic conditions, is an effective fertiliser that can nourish the healing forest for residents.²⁹  

Self-sufficiency
In many cases, health facilities such as hospitals, allied health centres and medi-hotels are decentralised and disconnected from their primary users, including patients and medical staff. The result is an inefficient delivery of healthcare consuming greater than necessary resources and inputs.³⁰ As a self-sufficient health precinct, HealthCite co-locates the associated health functions to meet all individuals’ needs at the one location. 

The proximity of a private hospital, retirement village, community health facilities, medi-hotel and key worker housing enables the streamlined delivery of comprehensive healthcare to patients. The locality enables centralised IT services, which can extend to implementing electronic medical records (EMRs) across the site and communicating with other sites. 

The objective of the hospital is to provide a balanced case-mix of generalist and specialist health, which caters for the current generation and is designed with the future in mind so it can cater for generations that follow.  

Given the aged care industry is predicted to grow at 5.1 per cent over the next five years, it’s expected that the ageing population will have the largest impact on demand for health services, resulting in an increased number of hospital admissions, bed days and use of resources.³¹ The co-location of aged care facilities and a retirement village will reduce patient transportation challenges and enhance accessibility to medical services.³² 

The transition of patients from the hospital to the home has been associated with low satisfaction of care and high hospitalisation rates.^33,34 In addition, Naylor et al³⁵ concluded that focus needs to be directed towards moving older adults into community-based transitional care, and increasing transition in acute hospital settings, as well as patient transition between facilities.  

The Childcare and Child Health Services building will consist of primary care suites, a kindergarten, an early-childhood development centre, retail, a gym, and a wellness centre. The objective of this facility is to create a community health benefit that contributes to the holistic wellbeing of all precinct occupants, including both staff and patients. In providing convenient childcare services, medical staff are better able to balance their family and work commitments and in providing recreational facilities, recovering patients can access rehabilitation at the one site.

The medi-hotel caters for ongoing medical care in the precinct in comfortable and safe accommodation, outside of the hospital facility. The medi-hotel assists in reducing the pressure for high-cost acute beds in hospitals by providing alternative overnight accommodation, such as for obstetrics and for visiting regional patients as they enter and leave the hospital system.³⁶ In addition, the medi-hotel can provide a simpler solution for foreign patients who travel for medical tourism.³⁷ Providing hospital resources and hotel services at an economically affordable price point, the medi-hotel increases the self-sufficiency of the precinct.

Between 2007 and 2012, the nurse attrition rate in Victoria was, on average, 34.2 per cent; given that 657 of the 2884 full-time employees at HealthCite Cardinia will be nurses, it’s essential that there is affordable key-worker housing in the direct vicinity of the precinct.²¹ As such, HealthCite will offer key-worker housing to mitigate medical staff supply issues and ensure there is stable employment in the precinct.

Based on the key sustainability indicators adopted, processes will be devised relevant to water treatment that follow the lifecycle design as shown in figure 7. Storm and rainwater will be harvested and treated to be used for all facets of the precinct, such as sewerage, laundry and landscape irrigation. This last aspect will be used to grow the forest and food, thereby providing a communal atmosphere for farming activities.³⁸ Produce from this garden will feed and provide for those residents who farmed it, encapsulating the self-sufficient cycle within the precinct.

Wellness promotion 
HealthCite’s project vision is to cater to the whole life of health, which entails viewing the individual as a holistic being with physical, physiological and psychosocial needs. Wellness and the ability for individuals to live well at every age is core to the precinct’s design. It will be reflected in both the physical design elements and the approach taken to develop and operate the precinct. 

Understanding therapeutic design on wellness in a clinical setting
The psychological and spiritual concept of wellness is supported by the philosophy of healing. In recent decades, research on healthcare design and planning has highlighted the considerable impact that environmental factors have on wellness. Studies show that patients in a room with a view of nature recover more rapidly and with improved emotional wellbeing compared to patients in similar rooms but who lack a view of nature.²⁵ As such, the physical and social environment has been proven to play a significant role in the wellness outcomes of both patients and staff.

Recognising that a well thought-out hospital design can help reduce pain, anxiety and stress for enhanced comfort and safety, HealthCite has adopted a healing environment approach in designing the precinct. Guildfords has adopted EBD as a tool to foster the social, psychological, physical, spiritual and behavioural aspects of holistic healthcare.³⁹ HealthCite will integrate EBD to create a biophilic and therapeutic environment that improves patient wellbeing. In addition, EBD will have a positive impact on staff efficiency and promote wellness for all hospital occupants. 

Wellness through connection to nature
Effective design measures are prioritised to integrate nature into the clinical setting. Various studies have validated the intuitive assumption of nature’s positive effect on wellbeing, and results have ranged from shorter post-operative stays in hospitals to a decrease in pain-relief drugs administered.³⁹ 

Natural lighting 
By softening the hospital environment with natural lighting, a healing environment can be cultivated for all occupants. Not only does daylight provide a more pleasant and attractive indoor environment, it encourages higher performance and productivity of staff, and enhances occupant comfort and patient recovery.⁴⁰ Specifically, ultraviolet light enhances healing by increasing protein metabolism, decreasing strain fatigue, stimulating white blood-cell production, increasing the release of endorphins, decreasing blood pressure and, generally, promoting health and emotional wellness.³⁹ 

The healing forest
To facilitate the positive interactions between people and nature, the precinct will feature a healing forest, which will provide a healthy, biophilic environment.⁴¹ The intended effect is to reconnect people with nature to improve mental and physical nourishment.⁴² 

The healing forest offers passive engagement, whereby a simple opportunity to view foliage, flowers, water and other natural elements can improve stress and patient wellbeing.^43,44 The healing forest will yield multiple natural health benefits (table 1) linked to the three primary mind-body systems that impact people’s wellbeing:

• cognitive functionality and performance: strong connections with nature provide opportunities for mental restoration to improve an individual’s mental agility, memory, and ability to think, learn and deliver outputs either logically or creatively;
• psychological health and wellbeing: experiences of natural environments provider greater emotional restoration, with lower instances of tension, anxiety, anger, fatigue and confusion; and
• physiological health and wellbeing: a physiological and physical response to nature involves the relaxation of muscles, as well as the lowering of diastolic blood pressure and stress hormones (cortisol) levels in the blood stream.⁴⁵ 

Placemaking strategies in promoting wellness
Aside from physical design, HealthCite’s social setting is also a priority in promoting wellness. Healthcare providers can create a healing environment by incorporating an atmosphere of safety, trust and openness. As such, a therapeutic environment should reflect the values, beliefs and philosophies of the patients served. 

Community and belonging
The provision of healthcare that covers the entire age spectrum, from providing obstetrics and childcare to various aged-care living arrangements, is a requisite to the successful integration of the hospital and its surrounding complementary entities. This includes connection to the broader community. 

Patient-centred care
HealthCite has adopted a model of care that focuses on the optimised delivery of health services along the age continuum of care. To meet this gradation concept, as referred to in figure 6, an interdisciplinary approach to health service delivery has been adopted; for example, HealthCite provides housing options for all stages of life. The co-location of retirement villages and apartments in proximity to the health precinct will cater, initially, for the downsizing retiree, and HealthCite employees as key-worker and affordable housing. This development provides a framework for an easier and less-anxious transition to various housing options, as people progress through the age cycle. 

Benefits of the concept design 

Better healthcare
The integrated nature of HealthCite will deliver a new level of co-ordinated health service across all generations throughout the community. This co-location of health services, community infrastructure, recreational activities and residential housing in the single precinct is designed from the ground up to support a new level of community health and wellbeing, improving overall health outcomes. Composition and proximity of complementary amenities provide readily accessible support, education and care services, supported by sophisticated IT connectivity, so that patients can expect prompt and efficient delivery of world-class health facilities as they move through varying levels of care. Overlaying this integration is the philosophy of a healing environment facilitated through smart design, which helps create a positive experience for all individuals and families by promoting holistic healthcare. 

Capitalise on interactions
The conglomeration of health, social and business services in the precinct creates a viable business model by increasing efficiencies of scale and operation. The main point of differentiation lies in the precinct itself, which offsets hospital profitability risks against the co-operation and partnership of aged care, medi-hotel, childcare, primary health, and neighbouring private and public hospitals. 

Potential to replicate
HealthCite can be replicated in various commercial settings. With established business, finance, risk and governance procedures, the precinct is a self-supporting entity with a concept design that can be delivered to multiple locations in Australia and internationally, given a developed government health support system. 

Limitations of the concept design 

Co-ordination issues
A successful precinct requires the co-ordination of multiple stakeholders and operators. Individual entities, however, may elect to operate independently, rather than collaborating to achieve the common objectives of the precinct. Although this may lead to an inconsistent brand across the replicated precincts and a management that’s disjointed in nature, HealthCite has established guidelines to ensure that each operator signed on shares the common objectives of the precinct. 

Land constraints  
The development of an integrated health precinct, such as HealthCite Cardinia, requires a large parcel of land. The acquisition and development of an appropriate site can, however, be difficult and expensive, especially in densely populated metropolitan areas. As such, an integrated health precinct is more likely to be feasible in metropolitan outer areas, where initial land cost is low but where population growth is high. In the context of HealthCite Cardinia, this is an opportunity to take advantage of the large land parcels available in outer growth corridors. Differentiation of the precinct also lies in the precinct itself, which offsets hospital profitability risks against co-operation and partnership of aged care, medi-hotel, child care, and primary and allied health. This takes pressure off the need to acquire larger parcels of land. 

Policy barriers
The health sector requires governmental support at local, state and federal levels, but because the concept of a health precinct is still relatively new, government often provides a lack of clarity in the zoning of a precinct. The immediate objective is therefore to educate government on the benefits of integrated health precincts. 

Lasting impact 
HealthCite, as a conceptual design, intends to create a replicable and integrated solution to future health challenges in high-growth areas. In addition, HealthCite will not only provide self-sufficiency in the precinct but also to the surrounding community through the provision of jobs, public spaces, and community health services. HealthCite will aid in the centralised provision of healthcare for more efficient and healthier cities. 

HealthCite is the architectural framework for integrated health service provision moving into the future. Its fundamental design is to create a welcoming environment for the provision of multi-generational, multi-faceted healthcare built on the three pillars outlined above. HealthCite identifies suitable sites by conducting a situation analysis based on the following criteria: 

• economic parameters;
• disease incidence and research support; 
• competitive analysis; 
• government policy and legislation; and 
• aged-care analysis. 

Following these criteria and framework, this model of healthcare provision can be replicated in key growth corridors throughout Australia and beyond. 

Authors
Dr Robert Payne is managing director at Guildfords Funds Management. Calvin Chan, Vivian Lu, Shona Li, and Ethan Kravietz are business analysts at the company.

Acknowledgement
The authors also acknowledge the advice and support of: Shalain Singh, national director transaction services, head of healthcare and retirement living, Colliers; George Savvides, director, CFMC Consulting (trading as Sodia); Christon Batey-Smith, director, DesignInc Melbourne; and Alex Rodger, director, NDY Management.