Exhibit O - Mental Health Outpatient Services Guide.pdf

PG 18-12 – MENTAL HEALTH OUTPATIENT SERVICES DESIGN GUIDE JULY 23, 2018

TABLE OF CONTENTS i

Mental Health Outpatient Services

Design Guide July 2018

TABLE OF CONTENTS i

TABLE OF CONTENTS

1.0 General .............................................................................................................. 1-1

1.1. Foreword ............................................................................................ 1-1

1.2 Acknowledgement .............................................................................. 1-3

1.3 Introduction ....................................................................................... 1-12

1.4 VA Policies/Standards and Industry Codes/Standards ..................... 1-14

1.5 Abbreviations .................................................................................... 1-17

2.0 Narrative ............................................................................................................ 2-1

2.1 General ............................................................................................... 2-1

2.1.1 Clinical and Operational Summary ..................................................... 2-1

2.1.1.1 Introduction ............................................................................... 2-1

2.1.1.2 Guiding Principles ..................................................................... 2-2

2.1.1.3 VA Mental Health Outpatient Services Delivery Locations ....... 2-3

2.1.2 Outpatient Mental Health Services ..................................................... 2-4

2.1.2.1 Introduction ............................................................................... 2-4

2.1.2.2 Level 1: Self-Directed Care ....................................................... 2-5

2.1.2.3 Level 2: Primary Care Mental Health Integration (PCMHI) ....... 2-6

2.1.2.4 Level 3: General Mental Health Services .................................. 2-8

2.1.2.5 Level 4.a: Specialty Mental Health Services ............................. 2-9

2.1.2.6 Level 4.a.1: Services Provided by Post-Traumatic Stress Disorders Clinical Teams (PCT) ................................................... 2-9

2.1.2.7 Level 4.a.2: Intensive Outpatient Specialty Mental Health Care, including Substance Use Disorder (SUD) .................................... 2-9

2.1.2.8 Level 4.a.3: Special Interventions ........................................... 2-12

2.1.2.9 Level 4.b: Community Based/Focused Programs ................... 2-14

2.1.2.10 Level 4.b.1: Psychosocial Rehabilitation and Recovery Center (PRRC) ...................................................................................... 2-14

2.1.2.11 Level 4.b.2: Intensive Community Mental Health Recovery (ICMHR) Programs .................................................................... 2-15

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2.1.2.12 Level 4.b.3: Therapeutic and Supported Employment Services (TSES) ....................................................................................... 2-16

2.1.2.13 Level 4.b.4: VHA Homeless Programs ................................. 2-17

2.1.3 VA Trends in Outpatient Mental Health Services.............................. 2-19

2.1.3.1 Shift from Inpatient to Outpatient Services ............................. 2-19

2.1.3.2 Expansion of Service Offerings .............................................. 2-19

2.1.3.3 Integration of Behavioral Health into Primary Care ................. 2-19

2.1.3.4 Increased Team-Based Care .................................................. 2-21

2.1.3.5 Non-Institutional Treatment Environment ............................... 2-21

2.1.3.6 On-Stage and Off-Stage Design ............................................. 2-22

2.1.3.7 Use of Technology .................................................................. 2-25

2.1.4 Space Planning and Design Concepts ............................................. 2-28

2.1.4.1 Flexibility and Adaptability ...................................................... 2-28

2.1.4.2 Adjacency and Flow................................................................ 2-31

2.1.4.3 Interior Design and Wayfinding ............................................... 2-32

2.1.4.4 Accessibility ............................................................................ 2-32

2.1.4.5 Patient Privacy and Confidentiality ......................................... 2-32

2.1.4.6 Safety and Security................................................................. 2-34

2.1.4.7 Additional Design Considerations for PRRCs ......................... 2-35

2.1.4.8 Additional Design Considerations for CRRCs and HCHV Service Centers ...................................................................................... 2-35

2.1.5 Design Considerations for Specific Spaces ...................................... 2-37

2.1.5.1 Waiting and Reception ............................................................ 2-37

2.1.5.2 Patient Care Spaces ............................................................... 2-38

2.1.5.3 Staff Space ............................................................................. 2-46

2.1.5.4 Outdoor Space ....................................................................... 2-47

2.1.6 Renovation of Existing Facilities for Outpatient Mental Health ......... 2-48

2.2 Technical Considerations ................................................................. 2-54

2.2.1 VA Policies, Codes and Standards ................................................... 2-54

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2.2.2 Outdoor Therapeutic Spaces ............................................................ 2-56

2.2.3 Architectural...................................................................................... 2-57

2.2.3.1 Interior Design ........................................................................ 2-58

2.2.3.2 Patient and Staff Safety and Security Overview ..................... 2-66

2.2.3.3 Partitions ................................................................................. 2-67

2.2.3.4 Ceilings ................................................................................... 2-68

2.2.3.5 Interior Doors .......................................................................... 2-68

2.2.3.6 Windows and Glazing ............................................................. 2-69

2.2.4 Structural Design .............................................................................. 2-70

2.2.5 Heating, Ventilation and Air Conditioning Systems ........................... 2-70

2.2.5.1 General ................................................................................... 2-70

2.2.5.2 Outdoor Air Requirements ...................................................... 2-70

2.2.5.3 Noise Criteria .......................................................................... 2-70

2.2.5.4 HVAC Design Features .......................................................... 2-71

2.2.5.5 Indoor Mechanical Equipment Locations ................................ 2-71

2.2.6 Plumbing Systems ............................................................................ 2-72

2.2.6.1 General ................................................................................... 2-72

2.2.6.2 Domestic Water Systems ....................................................... 2-72

2.2.6.3 Sanitary, Vent and Storm Systems ......................................... 2-72

2.2.6.4 Natural Gas System................................................................ 2-72

2.2.6.5 Plumbing Fixtures ................................................................... 2-72

2.2.6.6 Medical Gas Systems ............................................................. 2-72

2.2.6.7 Seismic Requirements ............................................................ 2-72

2.2.7 Lighting and Electrical Systems ........................................................ 2-73

2.2.7.1 General ................................................................................... 2-73

2.2.7.2 Lighting .................................................................................. 2-73

2.2.7.3 Power ..................................................................................... 2-74

2.2.8 Telecommunications, and Special Telecommunications, Monitoring and Signal Systems ................................................................................. 2-74

TABLE OF CONTENTS iv

2.2.8.1 General ................................................................................... 2-74

2.2.8.2 Telecommunications Network Outlets .................................... 2-75

2.2.8.3 Telemental Health Video-Conferencing .................................. 2-75

2.2.8.4 Nurse Call ............................................................................... 2-75

2.2.8.5 Television ............................................................................... 2-75

2.2.8.6 Security ................................................................................... 2-75

2.2.8.7 Duress Alarm .......................................................................... 2-76

2.2.8.8 PACS (Physical Access Control System) ............................... 2-76

2.2.8.9 Video Assessment and Surveillance ...................................... 2-76

2.2.8.10 Radio Systems (Site Specific Requirement) ......................... 2-77

2.2.8.11 Public Address System (PAS) .............................................. 2-77

2.2.9 Fire Protection and Life Safety ......................................................... 2-78

2.2.9.1 General ................................................................................... 2-78

2.2.9.2 Automatic Sprinkler................................................................. 2-78

2.2.9.3 Seismic Requirements ............................................................ 2-78

2.2.9.4 Fire Alarm ............................................................................... 2-78

3.0 Functional Diagrams .......................................................................................... 3-1

3.1 Introduction ......................................................................................... 3-1

3.2 Universal Module ................................................................................ 3-2

3.2.1 VHA Space Need / Utilization Toolkit ................................................. 3-4

3.2.2 Operational Assumptions for the Universal Module ............................ 3-8

3.2.3 Design Priorities and Advantages of the Universal Module Approach ... 3-9

3.3 Flexibility and Adaptability at the Room-by-Room Level .................. 3-11

3.3.1 Basic Clinical Office Module ............................................................. 3-11

3.3.2 Team Work Areas and Conference Space ....................................... 3-14

3.3.3 Group Care Rooms .......................................................................... 3-16

3.3.4 Intensive Outpatient Specialty Mental Health Care, including Substance Use Disorder (SUD) .......................................................................... 3-18

3.4 Flexibility and Adaptability at the Clinic Module Level ...................... 3-20

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3.5 Facilities for Community Based Programs ........................................ 3-22

3.5.1 Psychosocial Rehabilitation and Recovery Centers (PRRC) ............ 3-22

3.5.2 Community Resource and Referral Centers (CRRC) and Health Care for Homeless Veterans (HCHV) Service Centers ............................. 3-24

4.0 ROOM TEMPLATES – FLOOR PLANS, REFLECTED CEILING PLANS, ROOM

DATA SHEET, EQUIPMENT LIST & GENERAL NOTES ................................. 4-1

4.1 General ............................................................................................... 4-4

Introduction ................................................................................................... 4-4

Legend of Symbols........................................................................................ 4-6

4.2 Transcranial Magnetic Stimulation (TMS) Room (XXYYC) ................. 4-9

• 4.2 TMS Room - Axonometric ............................................................ 4-9

• 4.2 TMS Room - Floor Plan ............................................................. 4-10

• 4.2 TMS Room - Reflected Ceiling Plan ........................................... 4-11

• 4.2 TMS Room - Room Data Sheet ................................................. 4-12

• 4.2 TMS Room - Equipment List ...................................................... 4-14

4.3 Group Therapy Room (OPMH1) ....................................................... 4-16

• 4.3 Group Therapy Room – Axonometric ......................................... 4-16

• 4.3 Group Therapy Room – Reflected Ceiling Plan ......................... 4-18

• 4.3 Group Therapy Room – Room Data Sheet ................................ 4-19

• 4.3 Group Therapy Room – Equipment List .................................... 4-21

4.4 Group Therapy Room, Conference Format (XXYYC) ...................... 4-23

• 4.4 Group Therapy Room, Conference Format – Axonometric ....... 4-23

• 4.4 Group Therapy Room, Conference Format – Floor Plan .......... 4-24

• 4.4 Group Therapy Room, Conference Format – Reflected Ceiling Plan .........................................................................................................4-25

• 4.4 Group Therapy Room, Conference Format – Room Data Sheet ... 4-26

• 4.4 Group Therapy Room, Conference Format – Equipment List .... 4-28

4.5 OFFICE, CLINICAL, SINGLE ACCESS (XXYYC) ............................ 4-30

• 4.5 Office, Clinical, Single Access – Axonometric ............................ 4-30

• 4.5 Office, Clinical, Single Access – Floor Plan ............................... 4-31

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• 4.5 Office, Clinical, Single Access – Reflected Ceiling Plan (2 options) ............................................................................................................. 4-32

• 4.5 Office, Clinical, Single Access – Room Data Sheet ................... 4-33

• 4.5 Office, Clinical, Single Access – Equipment List ........................ 4-35

4.6. OFFICE, CLINICAL, DUAL ACCESS (XXYYC)................................ 4-37

• 4.6 Office, Clinical, Dual Access – Axonometric .............................. 4-37

• 4.6 Office, Clinical, Dual Access – Floor Plan .................................. 4-38

• 4.6 Office, Clinical, Dual Access – Reflected Ceiling Plan (2 options) ............................................................................................................... 4-39

• 4.6 Office, Clinical, Dual Access – Room Data Sheet ...................... 4-40

• 4.6 Office, Clinical, Dual Access – Equipment List ........................... 4-42

4.7 CONSULTATION ROOM, SINGLE ACCESS (XXYYC) ................... 4-43

• 4.7 Consultation Room, Single Access – Axonometric .................... 4-43

• 4.7 Consultation Room, Single Access – Floor Plan ........................ 4-44

• 4.7 Consultation Room, Single Access – Reflected Ceiling Plan (2 options) ................................................................................................. 4-45

• 4.7 Consultation Room, Single Access – Room Data Sheet ............ 4-46

• 4.7 Consultation Room, Single Access – Equipment List ................. 4-48

4.8 CONSULTATION ROOM, DUAL ACCESS (XXYYC) ....................... 4-49

• 4.8 Consultation Room, Dual Access – Axonometric ....................... 4-49

• 4.8 Consultation Room, Dual Access – Floor Plan .......................... 4-50

• 4.8 Consultation Room, Dual Access – Reflected Ceiling Plan (2 options) ................................................................................................. 4-51

• 4.8 Consultation Room, Dual Access – Room Data Sheet .............. 4-52

• 4.8 Consultation Room, Dual Access – Equipment List ................... 4-54

4.9 FAMILY CONSULTATION/THERAPY ROOM (XXYYC) .................. 4-55

• 4.9 Family Consultation/Therapy Room - Axonometric .................... 4-55

• 4.9 Family Consultation/Therapy Room – Floor Plan ....................... 4-56

• 4.9 Family Consultation/Therapy Room – Reflected Ceiling Plan .... 4-57

• 4.9 Family Consultation/Therapy Room – Room Data Sheet ........... 4-58

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• 4.9 Family Consultation/Therapy Room – Equipment List ............... 4-60

4.10 MULTIPURPOSE ROOM (OPMH1) ................................................. 4-62

• 4.10 Multipurpose Room - Axonometric ............................................. 4-62

• 4.10 Multipurpose Room – Floor Plan ................................................ 4-63

• 4.10 Multipurpose Room – Reflected Ceiling Plan ............................. 4-64

• 4.10 Multipurpose Room – Room Data Sheet .................................... 4-65

• 4.10 Multipurpose Room – Equipment List ........................................ 4-67

4.11 GROUP TESTING ROOM (OPMH2) ................................................ 4-69

• 4.11 Group Testing Room - Axonometric ........................................... 4-69

• 4.11 Group Testing Room – Floor Plan.............................................. 4-70

• 4.11 Group Testing Room – Reflected Ceiling Plan ........................... 4-71

• 4.11 Group Testing Room – Room Data Sheet ................................. 4-72

• 4.11 Group Testing Room – Equipment List ...................................... 4-74

4.12 SOCIAL ACTIVITIES/DINING/MULTIPURPOSE ROOM (XXYYC) .. 4-76

• 4.12 Social Activities/Dining/Multipurpose Room - Axonometric ........ 4-76

• 4.12 Social Activities/Dining/Multipurpose Room – Floor Plan ........... 4-77

• 4.12 Social Activities/Dining/Multipurpose Room – Reflected Ceiling Plan ............................................................................................................... 4-78

• 4.12 Social Activities/Dining/Multipurpose Room – Room Data Sheet ............................................................................................................... 4-79

• 4.12 Social Activities/Dining/Multipurpose Room – Equipment List ... 4-81

4.13 ACTIVITIES/DINING ROOM WITH KITCHENETTE (XXYYC) ......... 4-83

• 4.13 Activities/Dining Room with Kitchenette - Axonometric .............. 4-83

• 4.13 Activities/Dining Room with Kitchenette – Floor Plan ................. 4-84

• 4.13 Activities/Dining Room with Kitchenette – Reflected Ceiling Plan ............................................................................................................... 4-85

• 4.13 Activities/Dining Room with Kitchenette – Room Data Sheet ..... 4-86

• 4.13 Activities/Dining Room with Kitchenette – Equipment List ......... 4-88

4.14 ACTIVITIES/DINING ROOM (FSCD1) ............................................. 4-90

• 4.14 Activities/Dining Room - Axonometric ........................................ 4-90

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• 4.14 Activities/Dining Room – Floor Plan ........................................... 4-91

• 4.14 Activities/Dining Room – Reflected Ceiling Plan ........................ 4-92

• 4.14 Activities/Dining Room – Room Data Sheet ............................... 4-93

• 4.14 Activities/Dining Room – Equipment List .................................... 4-95

4.15 OCCUPATIONAL THERAPY ROOM (OTGC1) ................................ 4-97

• 4.15 Occupational Therapy Room - Axonometric .............................. 4-97

• 4.15 Occupational Therapy Room – Floor Plan ................................. 4-98

• 4.15 Occupational Therapy Room – Reflected Ceiling Plan .............. 4-99

• 4.15 Occupational Therapy Room – Room Data Sheet ................... 4-100

• 4.15 Occupational Therapy Room – Equipment List ........................ 4-102

4.16 CONFERENCE ROOM/CLASSROOM (XXYYC) ........................... 4-105

• 4.16 Conference Room/Classroom – Axonometric – conference format .............................................................................................................4-105

• 4.16 Conference Room/Classroom - Floor Plan – conference format ............................................................................................................4-106

• 4.16 Conference Room/Classroom – Reflected Ceiling Plan ........... 4-107

• 4.16 Conference Room/Classroom – Room Data Sheet .................. 4-108

• 4.16 Conference Room/Classroom – Equipment List – conference format ...................................................................................................4-110

4.17 METHADONE AREA (XXYYC) ...................................................... 4-112

• 4.17 Methadone Area - Axonometric................................................ 4-112

• 4.17 Methadone Area – Floor Plan .................................................. 4-113

• 4.17 Methadone Area – Reflected Ceiling Plan ............................... 4-114

• 4.17 Methadone Area – Room Data Sheet ...................................... 4-115

• 4.17 Methadone Area – Equipment List ........................................... 4-117

5.0 Appendix ........................................................................................................... 5-1

Index of Figures and Tables: ............................................................................... 5-1

TABLE OF CONTENTS ix

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GENERAL 1-1

1.0 General

1.1. Foreword

The Department of Veterans Affairs (VA) Program Offices, project teams, designers and constructors, are obligated to our Nation's Veterans and taxpayers to make the most effective and efficient use of resources, by providing a continuum of safe, secure, high quality, high performance, and high value environments of care and service for Veterans. The VA Office of Construction and Facilities Management (CFM) supports the Department's mission through development and application of standards as a basis for disciplined planning, design, and construction of VA facilities.

VA Standards are the culmination of a partnership among the Department of Veterans Affairs (VA), Veterans Health Administration Program Officials and Clinicians, Industry, Academic and Research Organizations, Expert Consultants, and the Office of Construction and Facilities Management. Design Guides are developed through integration of VA-specific requirements, Federal law and regulation, benchmarking of industry best practice, evidence-based research and design, and value-based analysis of leading edge innovation. The result is the establishment of best value standards for optimum functionality, safety, operability, performance, and quality throughout the VA environment of care and service.

Design Guides (PG-18-12) are a critical component of the VA Technical Information Library (TIL) (www.cfm.va.gov/TIL) which contains standards for all VA planning, design, and construction projects. Design Guides focus on selected healthcare departments and services, and include an overview narrative of VA-specific planning and design principles and concepts, room templates, equipment lists, and basic technical/engineering requirements. They communicate the basis of design and are required to be utilized by project teams working on new construction projects and renovations of existing facilities. Design Guides will maximize the effectiveness and efficiency of the planning and design process and ensure a high level of design, while controlling construction, operating, and maintenance costs.

The information contained in Design Guides constitutes a Standard for VA Planning, Design and Construction. For all VA projects, it is required that project teams comply with the following in all phases of project development:

1) All applicable VA Standards published in the VA Technical Information Library (TIL) shall be applied as a basis, foundation, and framework in planning, design, and construction. Any substantial variance from Standards shall be considered http://www.cfm.va.gov/TIL

GENERAL 1-2

only as required to accommodate specific site, functional, and operational conditions. Upon consideration of variance, CFM shall be consulted, and VA will function as Authority Having Jurisdiction for decision. Each substantial variance shall have a basis rationale and be documented in the project record

2) Clinicians, providers, primary users, and other stakeholders shall be involved in all phases of project development to best adapt Standards for specific functional, operational, and site conditions, and to provide optimum service environments for Veterans. This also includes installations and modifications of systems or technology involving safety, security, functionality, or environmental quality. Stakeholder involvement shall be documented in the project record.

Design Guides are not project‐specific. It is impossible to foresee all rapidly evolving requirements of healthcare facilities and each site or project will have unique requirements or conditions. Site‐specific issues must be addressed within the context of these standards and applied to each individual project. Use of this Guide does not preclude the need for, nor absolve planners, architects, and constructors of their responsibility to provide complete, functional, safe, and secure designs suited to the unique requirements of each project, within budget, and on schedule.

Material, equipment and systems are shown in an illustrative, performance-based format and are not intended to depict, suggest, or otherwise constitute endorsement of any specific product or manufacturer. Manufacturers should be consulted for actual dimensions, configurations, and utility requirements.

All participants in the project development process must embrace VA Planning, Design and Construction Standards as fundamental in providing optimum environments for Veterans’ care and services, in fulfilling VA's mission.

GENERAL 1-3

1.2 Acknowledgement

Credit is due to the following individuals whose leadership, knowledge, skills, and ability made this document possible:

Department of Veterans Affairs, Veterans Health Administration (VHA)

Office of Mental Health and Suicide Prevention (10NC5)

Loren Wilkenfeld, Psychologist National Mental Health Director for Inpatient and Outpatient Policy, Ret.

Peggy Henderson, Psy. D. Deputy Director, Psychosocial Rehabilitation and Recovery (VACO)

Jay Cohen, Ph.D., LP MH Technical Assistance and Business Operations (VHA OMHSP)

Mark Bondeson Associate Chief of Staff for Behavioral Health, Boise VA Medical Center

Marsden McGuire, MD, MBA Director, Continuum of Care and General Mental Health Services (OMHSP)

Clifford Smith, MD Director, Field Support and Data Analytics, Office of Mental Health and Suicide Prevention (10NC5)

Karen Drexler, MD National Mental Health Program Director – Substance Use Disorders (SUD), OMHSP, VA Central Office

Kendra Weaver, Psy.D. Senior Consultant, Mental Health Clinical Operations (OMHSP)

Hugh Myrick, MD ACOS, Mental Health Services Line (RHJ

VAMC)

Peter D. Mills, Ph.D., MS Director – VA National Center for Patient Safety Field Office, Adjunct Associate Professor of Psychiatry, The Geisel School of Medicine at Dartmouth

Andrew S. Pomerantz, MD National Mental Health Director, Integrated Services (OMHSP)

GENERAL 1-4

Matt Miller, Ph.D., MPH Director, Veterans Crisis Line

Susan K. Hoopengarner Program Support Assistant, PSR&RS

Timothy R. Smith, Ph.D. Psychologist and National Director, Inpatient and Outpatient Psychosocial Rehabilitation and Recovery Services, VACO – Office of Mental Health and Suicide Prevention (10NC5)

Michal Wilson, MD Medical Director, Homeless Programs

Allison Bond, LCSW CRRC & HCHV Outreach National Program Manager, VHA Homeless Programs

Shana Bakken, PhD Director, Therapeutic and Supported Employment Services

Environmental Program Service (EPS)

Vonda K. Broom Deputy Director, Environmental Programs Service (10NA7)

Christine Emanuelson, NCIDQ Program Manager, Interior Design, VHA Environmental Programs Service (10NA7)

Office of Capital Management Engineering Services (OCAMES)

Don Wainwright, FACHE Compliance Engineer, Office of Capital Asset Management and Engineering Support

Telecommunications

Forrest Frakes, PG, (FCC), CET, PC Senior Telecommunications Specialist

Keith A. Van Bakel, ATS Telecommunications Specialist, VACO, OSP (007A)

GENERAL 1-5

Department of Veterans Affairs (VA)

Office of Construction and Facilities Management (CFM)

Donald L. Myers, AIA Director, Facilities Standards Service

Kayvan Madani Nejad, Ph.D., AIA Senior Healthcare Architect, Project Manager

Gary Fischer, AIA Senior Healthcare Architect

Fei (Linda) Chan, Assoc. AIA, NCARB Planner

Rand Hakim, AIA, NCARB Senior Healthcare Architect/Planner

Matt Shepardson, MHS, MSIR Senior Planner

Jacob J. Brown Medical Equipment Specialist

Dave Tash, PE, LEED AP BD+C Mechanical Engineer, Subject Matter Expert

Lam Vu, PE, CEM Senior Electrical Engineer

Nathan Sears, RA, MBA, CGC, AVS Value Manager

Mark Goeller, RA, M.Arch Architect, SME

Fred Lau, PE Structural Engineer

Juan Archilla, PE Structural Engineer

Michael Taylor, PE, LEED AP Senior Mechanical Engineer

Scott D. Hurst Contracting Officer

Orest Burdiak Principal Interior Designer

David Treece OCFM Consulting Support Service (003C5), Architecture

Ward Newcomb, MD, MMM Director of Integrated Clinical Design, Palo Alto Veterans Healthcare System, Consultant PACT Space and Operations, VACO Primary Care Services 10P4F

GENERAL 1-6

VA Center for Innovation

Melissa Chapman Chief Designer

Amber Schleuning Deputy Director

VA Medical Centers

Katrina Johnson Norris R.A. Space Planner, VA Tennessee Valley Healthcare System

Margaret Healy, MSN, RN-BC PMHN Program Manager, Outpatient Mental Health VA St. Louis Health Care System, St. Louis, MO

Shannon Fragmin, RN, CEN Nurse Manager, OPBH, Louis A. Johnson VA Medical Center, North Central West Virginia

Catherine Woodman, MD Director, Outpatient Mental Health. Iowa City VA Health Care System, Iowa City, IA

Julie Low, MD Director, Mental Health Clinic, Philadelphia, PA

Anthony Thompson, BSBA, CPSS Charlotte HCC, W.G. (Bill) Hefner VA Medical Center, Salisbury, NC

Michael W. Roach, LCSW-BACS Deputy Associate Chief of Staff for Mental Health, Alexandria VA Healthcare System, Pineville, LA

Glenn G. Wikel, Jr., MS Business Manager, Behavioral Health and Sciences Care Lines, Lebanon VA Medical Center, Lebanon, PA

Jesse Burgard, Psy.D. Director of Mental Health, VA Healthcare System of Indiana, Michigan and Ohio

(VISN 10)

Catherine Ayers, Ph.D. Section Chief, Outpatient Mental Health Clinics, VA San Diego Healthcare System

Melissa Taylor Memphis VA Medical Center, Memphis, TN

GENERAL 1-7

Site Visits

VA Palo Alto Health Care System

Steven Lindley, MD, Ph.D Director, Outpatient Mental Health, Tina T. Lee, MD, MS Deputy Chief of Staff, Mental Health

Ronald Suarez, MD Medical Director, VA South Bay Mental Health Clinics

Katranker Thompson, LCSW South Bay Clinical Coordinator (San Jose, Monterey and Capitola)

Dave Roberts, MBA, LCDR, USN (Ret.)

Process Improvement Specialist, Major General William H. Gourley (VA-DoD OPC)

James Romer, Architect Office of Facility Planning and Development

Beth Kane Program Analyst, Office of Deputy Director

Bill McGurk Office of Facility Planning and Development

Orlando VA Medical Center at Lake Nona

Paul Deci, MD Associate Chief of Staff/Mental Health

Steven J. Shea, Ph.D. Local Recovery Coordinator, Psychologist Program Manager, MH Recovery Programming and Transformation

Sree Yalamanchili, MD ACOS Ambulatory Care

Elaine Elmore, MSN, RN Mental Health Nurse Manager

April Engelbrecht AO to ACOS Ambulatory Care

Sandra Kirkland Chief Nurse, MH

Hina Lone Team Lead Patient Clinic

Margaret Amott PCMHI Program Lead

GENERAL 8

James A. Haley Veterans Hospital – Tampa, Florida

Glenn Catalano, MD Associate Chief of Staff for Mental and Behavioral Sciences

William Hervey, MD, MBA Program Lead, Substance Use Disorders Service

Mary Dorritie, Psychologist Acting Team Leader, Trauma Recovery Program

Angela Denietolis, MD Executive Director, Office of Primary Care

Ronald Gironda, Ph.D. Assistant Chief, MH&BS Service/Chief, Psychology Section

Brian Zilka, MD Assistant Chief, Ambulatory Care

Ben Lord PCMHI

Vanessa Milsom, Ph.D. Supervisory Psychologist, James A. Haley

VA

Lake Baldwin Outpatient Clinic, Orlando VA Medical Center

Steve Sabol Lake Baldwin Administrative Officer

Leslee Davis Lake Baldwin PC Section Chief

VA Ann Arbor Healthcare System

Brian Martis, MD Chief Psychiatrist

MaryGrace Lauver, LMSW Outreach Section Chief, Mental Health Service

Nancy Anderson Senior Interior Designer

Eric Deters Planning and Analysis

Erin Smith, Ph.D. PTSD Clinical Team Chief

Mark Lyubkin, MD Mental Health Clinic Chief

Joseph VanderVeen, Ph.D. SUD-IOP Clinic Chief

GENERAL 9

Deborah Wilson

Eric Pear, MS/MA Program Analyst

Robert Spencer, Ph.D. Neuropsychology Team Chief

Sarah Richards, LMSW Social Work

Liz Haas, LMSW Psychiatric Social Work

Reiko Buckles, LMSW Primary Care Mental Health Team Lead

Battle Creek VA Medical Center

Joseph L. Dudley, LCSW Chief, Social Work Service

Daleth C. Jean-Jules, MSSW, LMSW, FAC-COR

Homeless Continuum Program Manager

Tiyanna (Whitt) Payne, LMSW, ACSW

BCD

Healthcare for Homeless Veterans Supervisor

Susan Lee Peer Support Specialist

William Bloem, Ph.D., ABPP Associate Chief of Staff for Mental Health

Louis Stokes Cleveland VA Medical Center

Kevin J. Smith, Ph.D. Psychology

David Sabol, RA Chief of Engineering Service

George Jurjus, MD Director, Outpatient and Emergency Psychiatric Services

University of Michigan, Psychiatry Department

Thomas Fluent, MD Medical Director of Ambulatory Services

Tammy LaPrell Patient Account Supervisor

GENERAL 1-10

Kaiser Permanente, Oakland, San Rafael and Daly City, CA

John Kouletsis Vice President of Facilities Planning and Design

Tony Guarino Facilities Planning and Design

Linda Raker Facilities Planning and Design

Michelle Taylor Facilities Planning and Design

Jay Murphy National Facilities Services, Capitol Projects

Nick Winer The Permanente Medical Group

Ken Shigematsu Director, Department of Psychiatry, Kaiser Permanente, South San Francisco

Riley Guy The Permanente Medical Group

Frances Sooy National Facilities Services

Jody Clay National Facilities Services

Stefani Komaru The Permanente Medical Group

GENERAL 1-11

Consultants

Cannon Design

Tim Rommel, AIA, MRAIC, ACHA Principal, Behavioral Healthcare Practice Leader

David W. Esch, AIA Vice President

Gary P. Richmond, AIA, LEED AP, BD+C Associate Vice President

Theodore Fowler, PE, PEng, CDT Principal, Electrical Engineering

Christine Soto, NCIDQ Vice President

Jerome Bobak, PE Vice President, Mechanical Engineering

Ronald Curtis, PE Associate Vice President, Structural Engineering

Jon Beyer, CPD, CDT Associate Vice President, Plumbing and Fire Protection

F. Patrick Mahoney, RCDD, CDT Senior Associate

Kassam Master Technology Designer

David Sass, RA, LEED AP Senior Vice President

Cheri Weatherston, AIA Senior Associate

Stephanie Vito, AIA Associate Vice President

Sub-Consultants

The Innova Group

Chris Phillips Project Manager, Medical Equipment Planning

Eric Hunt Medical Equipment Planner

GENERAL 1-12

1.3 Introduction

The Mental Health Outpatient Services Design Guide was developed as a tool to assist VA clinical, contracting, planning, construction and engineering staff in better understanding the space, equipment and planning concepts for Outpatient Mental Health Services. The Guide addresses general space and equipment planning, as well as functional and technical requirements for outpatient mental health.

The A/E design team shall understand and be familiar with the most current editions of the applicable VA and industry codes and standards. VA design and construction standards can be accessed at the Office of Construction and Facilities Management’s Technical Information Library (TIL) (http://www.cfm.va.gov/TIL).

This VA Mental Health Outpatient Services Design Guide has been developed as a stand-alone document in contrast to the 2010/2014 edition of the VA Mental Health Design Guide, which addresses both inpatient and outpatient mental health care. It was determined that a single Design Guide could not efficiently address the extensive array of services that are provided by VA. Thus, separate documents for outpatient and inpatient care were deemed essential.

This document focuses on the continuum of outpatient services offered by the VA. It includes integration of mental health providers into primary care; general mental health clinics; specialty mental health outpatient programs; psychosocial rehabilitation and recovery centers; and a range of settings that provide health care to homeless Veterans.

Residential and inpatient mental health services will be covered in a separate Inpatient Mental Health Design Guide, to be updated and issued at a future date. Related and supporting programs covered in other Space Planning Criteria chapters and Design Guides include the following:

http://www.cfm.va.gov/TIL

GENERAL 1-13

TABLE 1: REFERENCES TO VA PROGRAMS RELATED TO OUTPATIENT MENTAL

HEALTH

Program / Service Cross-reference to:

Patient Aligned Care Teams (PACT) – Primary Care

Mental Health Outpatient Services Design Guide discusses Primary Care Mental Health Integration (PCMHI) Planning. Space and design standards for PCMHI must be considered when designing PACT Clinic Space

Mental Health treatment space in Emergency Departments

Refer to Space Planning Criteria Chapter 256 Emergency Department (ED) and Urgent Care Clinic (UCC)

Electroconvulsive Therapy (ECT) This procedure is done in Surgical Service

Mental Health Residential Rehabilitation Treatment Program

(MH RRTP)

Refer to 2010/2014 Mental Health Design Guide for residential programs.

Research Need for researcher workspace should be considered in the programming of mental health outpatient facilities. See also Space Planning Criteria Chapter 278 Research & Development.

GENERAL 1-14

1.4 VA Policies/Standards and Industry Codes/Standards

• VHA Handbooks, Directives and Policies: Refer to the most current published version.

1. VHA Handbook 1160.01, Uniform Mental Health Services in VA Medical Centers and Clinics (amended Nov 16, 2015)

2. VHA Handbook 1160.03, Programs for Veterans with Post-Traumatic Stress Disorder (PTSD), Revised Dec 8, 2015

3. VHA Handbook 1160.04, Programs for Veterans with Substance Use Disorders (SUD), Revised Dec 8, 2015

4. VHA Handbook 1160.05, Local Implementation of Evidence-Based Psychotherapies for Mental and Behavioral Health Conditions, Revised Dec 8, 2015

5. VHA Handbook 1162.05, Housing and Urban Development (HUD) – Department of Veterans Affairs Supported Housing (VASH) Program, Sept 14, 2011

6. VHA Handbook 1162.09, Health Care for Homeless Veterans (HCHV) Program, May 2, 2014

7. VHA Directive 1163, Psychosocial Rehabilitation and Recovery Services, July 1, 2011

8. VHA Handbook 1163.01, Psychosocial Rehabilitation and Recovery Services, July 1, 2011

9. VHA Handbook 1163.02, Therapeutic and Supported Employment Services Program, July 1, 2011

10. VHA Handbook 1163.03 Psychosocial Rehabilitation and Recovery Centers (PRRC), July 1, 2011

11. VHA Handbook 1163.05 Psychosocial Rehabilitation and Recovery Centers Peer Support, July 1, 2011

12. VHA Handbook 1163.06 Intensive Community Mental Health Recovery Services, January 7, 2016

13. VHA Directive 1501, VHA Homeless Programs, October 21, 2016

• VA Design and Construction Standards: Refer to the most current published version:

1. Master Construction Specifications PG-18-1

2. Design and Construction Procedures PG-18-3, including list of

Codes, Standards and Executive Orders

3. Standard Details and CAD Standards PG-18-4

GENERAL 1-15

4. Equipment Guide List PG-18-5

5. VHA Space Planning Criteria PG-18-9, Chapter 260: Mental Health

Outpatient Services, which updates and supersedes standards previously provided in Chapter 260: Mental Health Clinic, Chapter 202: Substance Abuse Clinic and Chapter 261: Day Treatment (“Psychosocial Rehabilitation and Recovery Center”)

6. Barrier-Free Design Handbook PG-18-13

7. Room Finishes, Door, and Hardware Schedule PG-18-14

8. Current version of Technical Criteria (Design Manuals PG-18-10), including:

• Architectural Design Manual

• Interior Design Manual

• HVAC Design Manual

• Plumbing Design Manual (PDM)

• Fire Protection Design Manual

• Lighting Design Manual (LDM)

• Electrical Design Manual (EDM)

• Telecommunications and Special Telecommunications Design

Manual (TDM)

• Physical Security Design Manual for Mission Critical Facilities

• Physical Security Design Manual for Life-Safety Protected

Facilities (PSDM)

9. VA Healing Environment Design Guidelines

10. Seismic Design Requirements H-18-8

• Industry Codes/Standards

1. FGI Guidelines for Design and Construction of Outpatient Facilities, including Specific Requirements for Outpatient Psychiatric Centers

2. International Building Code (IBC) including International Mechanical and Plumbing Codes

3. National Fire Protection Association (NFPA) 101 Life Safety Code

NFPA 101 primarily addresses life safety and fire protection features while the IBC addresses a wide range of considerations, including, but not limited to, structural strength, stability, sanitation, adequate light and ventilation, and energy conservation.

4. NFPA National Fire Codes with the exception of NFPA 5000 and

NFPA 900

GENERAL 1-16

5. Occupational, Safety and Health Administration (OSHA) standards

6. Uniform Federal Accessibility Standards (UFAS), including VA

Supplement Barrier Free Design Guide

7. The Healthcare Insurance Portability and Accountability Act of 1996

(HIPAA) protects individual’s rights to audible as well as visual privacy

GENERAL 1-17

1.5 Abbreviations

General Terms

A Amps

ABA Architectural Barriers Act

ACH Air Changes per Hour

AFF Above Finished Floor

AHJ Authority Having Jurisdiction

AIA American Institute of Architects

BICSI Building Industry Consulting Services

CCTV Closed Circuit Television System

CFM Office of Construction & Facilities Management

CMS Centers for Medicare and Medicaid Services

FC Foot Candle

FMS Facilities Management Service (Services)

HIPAA Health Insurance Portability and Accountability Act

HVAC Heating, Ventilating and Air Conditioning

IBC International Building Code

JSN Joint Schedule Number

LB Pound

LED Light Emitting Diode

LEED Leadership in Energy and Environmental Design

LUX Lumen Per Square Meter

MATV Master-Antenna Television

NFPA National Fire Protection Association

GENERAL 1-18

NSF Net Square Feet

NSM Net Square Meters

NTS Not to Scale

ORP VA Office of Real Property

OSHA Occupational Safety and Health Administration

PACS Physical Access Control System

PG Program Guide

RCDD Registered Communications Distribution Designer

SF Square Feet, Square Foot

SMS Safety Management System

SSTV Security Surveillance Television System

STC Sound Transmission Class

TIL Technical Information Library

TR Telecommunications Room

TV Television

UPS Uninterruptible Power Supply

V Volts

VA Department of Veteran Affairs

VACO Veterans Affairs Central Office

VAMC Veterans Affairs Medical Center

GENERAL 1-19

Mental Health Specific Terms

BHIP Behavioral Health Interdisciplinary Program

CARF Commission on Accreditation of Rehabilitation Facilities

CBES Community-Based Employment Services

CBOC Community Based Outpatient Clinic

CCC Co-located Collaborative Care

CRRC Community Resource and Referral Center

CWT Compensated Work Therapy

DTC Day Treatment Center

GMH General Mental Health

HCHV Health Care for Homeless Veterans

H-PACT Homeless – Patient Aligned Care Teams

HUD-VASH Housing and Urban Development – VA Supported Housing

ICMHR Intensive Community Mental Health Recovery

IOP Intensive Outpatient Program

MH RRTP Mental Health Residential Rehabilitation Treatment Program

MHICM Mental Health Intensive Care Management

PACT Patient Aligned Care Team

PCMHI Primary Care Mental Health Integration

PCT PTSD Clinical Team

PRRC Psychosocial Rehabilitation and Recovery Programs

PTSD Post-Traumatic Stress Disorder

RANGE Rural Access Network for Growth Enhancement Programs

SE Supported Employment

GENERAL 1-20

SEd Supported Education

SSE Supported Self-Employment

SMI Serious Mental Illness

SUD Substance Use Disorder

TBI Traumatic Brain Injury

TMS (rTMS) (Repetitive) Transcranial Magnetic Stimulation

TSES Therapeutic and Supported Employment Services

VARC Veteran Addiction Recovery Center

LOGISTICAL CATEGORIES (LOG CATS)

VV VA furnished and installed – Medical Care Appropriations

VC VA furnished and Contractor Installed – Medical Care Appropriations for Equipment and Construction Appropriations for Installation

CC Contractor Furnished and Installed – Construction Appropriations

CF Construction Appropriations – VA furnished. Installed by the Department of VA or Contractor

L_RE Leased / Rented Equipment

NARRATIVE 2-1

2.0 Narrative

2.1 General

2.1.1 Clinical and Operational Summary

2.1.1.1 Introduction

The Veterans Health Administration (VHA) operates one of the most comprehensive mental health care delivery systems. The continuum of mental health care provided within VHA covers a wide range of mental health conditions that may be experienced by Veterans. Access to the appropriate level of care and ongoing continuity of care are vital facility design issues. The VHA’s continuum of services for mental health is delivered in settings that include outpatient, intensive outpatient, residential, and inpatient care, as well as community based settings. Within each of these settings, services are provided to promote recovery and individual potential, with an emphasis on evidence-based practices.

TABLE 2: LEVELS OF CARE FOR VA MENTAL HEALTH

- Outpatient Residential Inpatie nt

Level 1 Level 2 Level 3 Level 4a Level 4b Level 5 Level 6

Self-directed care (biblio-therapy, web-based mental health programs, etc.)

PACT

(includes Primary Care Mental Health Integration

[PCMHI]

Providers)

General Mental Health (e.g.

Behavioral Health Inter-disciplinar y Program

[BHIP]

Team- Based Care)

Specialty Outpatient Programs (4a.1 PCT, 4a.2 SUD / IOP, 4a.3 Special Interventio ns)

Community- Based/ Focused Programs (4b.1 PRRC, 4b.2 ICMHR, 4b.3 TSES, 4b.4 Homeless Service Centers)

Residential Rehabilitati on & Treatment Programs (RRTPs)

Inpatie nt Mental Health Service s

NARRATIVE 2-2

Table 2 summarizes levels of care provided for VHA Mental Health services. These services will be defined in Section 2.1.2.1 and further described in the balance of Section 2.1.2 of this narrative. Levels 2 through 4 are the focus of this Outpatient Services Design Guide. Refer to VA Handbooks and Directives (list in Section 1.4 of this Design Guide) for additional guidance on design and services for other levels of care. Program acronyms are also defined in Section 1.5 of this Design Guide.

2.1.1.2 Guiding Principles

VHA health care is guided by principles including the need to provide high quality, timely, proactive, evidence-based, state-of-the-art, and holistic patient-centered care to Veterans. Mental health care in VHA is built upon the foundational principle of “recovery.” The definition of recovery used by VHA comes from the Substance Abuse and Mental Health Services Administration (SAMHSA) which states:

“[Recovery is] a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.”

Emphasis is placed on maximizing hope, meaning and individual potential. VHA is committed to promoting recovery in all patients, including those living with serious mental illness.

Mental health care delivery in VHA is delivered within an interprofessional team context, where team members interact and work together with the Veteran as partners in the treatment process. Interprofessional treatment teams are comprised of mental health professionals representing multiple disciplines as well as other professions. These professionals include, but are not limited to the following:

Addiction Therapists Advance Practice Nurses/Nurse Practitioners Chaplains Clinical Pharmacists Dieticians Licensed Practical Nurses Licensed Professional Counselors Licensed Vocational Nurses Marriage and Family Therapists Peer Specialists Psychiatrists Psychologists Recreational Therapists

NARRATIVE 2-3

Registered Nurses Rehabilitation Technicians Social Workers Vocational Rehabilitation Counselors/Specialists

A supportive care environment is essential to assisting each Veteran in her or his recovery journey. Recovery is facilitated by team-based care providing therapeutic programming in warm, calming, and peaceful physical settings that utilize natural light, comfortable space and furniture design, soothing colors and art.

A supportive work environment is essential to enabling care teams to offer the therapeutic programming that promotes patient recovery. Treatment areas for individual therapy, family therapy, group therapy, and rooms for psychoeducation classes all have a place in the treatment process. In addition, it is important to provide areas to support staff in their work responsibilities and to promote collaboration with their colleagues.

2.1.1.3 VA Mental Health Outpatient Services Delivery Locations

The outpatient component of the VA mental health care delivery system includes a wide range of specialized mental health treatment settings (see Section 2.1.2. for details).

These VA outpatient mental health services are most commonly included in:

• VA Medical Centers

• VA Outpatient Clinics, including Community Based Outpatient Clinics (CBOC), or

• Community-based settings that are not VA-based

For this third scenario, a Veteran may be referred to a community provider if they live too far from a VA facility, the needed specialist is not available, or the length of time is too long before they can be seen at a VA facility.

Through efforts to promote innovation in mental health care delivery and enhance service access and quality, outpatient mental health services are also increasingly being provided in non-mental health specialty settings including, but not limited to, Spinal Cord Injury Centers and Blind Rehabilitation Centers. Additionally, Veterans with mental health needs who find it burdensome to leave their homes and are otherwise eligible may receive services through the Home-based Primary Care (HBPC) program.

Note: The VHA Handbook 1160.01 Uniform Mental Health Services in VA Medical Centers and Clinics (amended Nov 16, 2015) defines program requirements for the mental health services that must be provided in CBOCs according to the size of the clinics. For VA space planning guidelines that pertain to CBOCs, refer to PG-18-9

NARRATIVE 2-4

Chapter 265 Outpatient / PACT Clinic and Prototype for…