Overview

This chapter addresses the selection of a site for developing, expanding, or adding a satellite primary health care site.

SITE SELECTION

Once the decision has been made to develop or expand a primary care center, the initial tendency is to quickly acquire space or land and hire an architect. We would caution against such an impulsive move. Careful planning is needed to ensure that the appropriate site is selected that best meets your needs.

SITE SELECTION COMMITTEE

The site selected for your primary care center is critical to its overall image and acceptability to the target population, staff and community. Therefore, it is important to involve representatives from each of these groups in the site selection process. A site selection committee should be formed to:

• develop the selection criteria based upon the community's objectives for the center;
• identify preliminary issues and concerns; and
• develop a plan of action.

The committee should include not only people directly involved with the organization of the primary care center, but also individuals that can bring specialized expertise to the process and representatives from the target population. For example, include:

• a local realtor who can provide information on:
  • existing space to lease or share;
  • land options; and
  • real estate market rates.
• a banker and/or lawyer who can provide information on contract negotiations, financing, terms, and regulatory or legislative issues (e.g., zoning);
• an architect/engineer who can provide valuable information on the appropriateness of the site:
  • if existing space, the extent of renovation required, code requirements and cost estimates;
  • if constructing a new facility, the suitability of the land for construction, any construction limitations due to code requirements, availability of water, sewer, utilities, etc.
• health care providers who will provide input regarding access, linkages and other related issues;
• city/county/regional representatives who can help provide information on health care initiatives, local land planning activities, zoning and transportation issues;
• a representative from the health department; and
• advocates for the target population who will bring the practical aspect to the site selection regarding the needs of the users.

A "plan of action" should be developed which:

• specifies the parameters of the site selection process;
• identifies the responsible individual for identifying the site options;
• sets out timelines for completion of the selection task; and
• delineates key activities and schedules for committee meetings.

SPACE OPTIONS

Each community will have its own requirements for space depending upon its primary health care goals, the scope of services to be provided (current and anticipated), the size of the population to be served and the availability of funding. It is common for a community just starting off with the development of a primary care center to look for inexpensive space to share with existing organizations, such as churches, schools, or health departments. As noted in Chapter 3, primary care centers often work with county social services or local hospitals to find potential site locations that are mutually beneficial. Beyond this type of space, you will need to consider a range of options when developing a new center or expanding an existing one, including:

• lease space in an existing building;
• purchase an existing facility and renovate the space; or
• construct a facility designed specifically for the primary care center.

Each option has its positive and negative points and must be considered carefully in terms of how it relates to the community's long-range objectives. Constructing a new facility is the most desirable in terms of design and future planning; however, the cost can be prohibitive for a startup center. Sharing space is a cost effective way to start an operation, but the operations may suffer due to the space layout. Renovating an existing facility often is more costly in the long run than building from scratch.

Each option will have to be analyzed to determine the right type of space for the center in the long term. A space development plan should be created which lays out an acquisition strategy for the future. You may not now be in a financial position to build a facility initially; however, your plan should provide your vision for how the center will look in the future so that planning can begin, not only on the facility, but also on its financing. For example, you may elect to start operations in space shared with the health department with plans to move into leased space in one year and construct a small center within five years. It is not unusual for health centers to develop their facilities in stages over time to accommodate growth in staffing, scope of service, utilization, and financial capacity.

SITE LOCATION POSSIBILITIES

Once the plan of action has been developed and the committee agrees on the type of space for the center, the designated individual can identify location possibilities that meet the site selection criteria. The next steps are to explore site options, begin discussions with the owners/landlords, analyze the strengths and weaknesses of the sites and prioritize the location possibilities.

One systematic and objective methodology for ascertaining the desirability of each site includes comparison of the following factors:

Functional Factors:

• relationship of the site to the population in the service area;
• relationship of the site to other health care providers/ agencies;
• relationship of the site to housing for the proposed center staff;
• major road access to the site and parking availability;
• accessibility to public transportation;
• zoning and quality of surrounding neighborhood;
• space must accommodate disabled persons, elderly patients, and training of students;
• size of the site related to building needs;
• site configuration/space availability;
• easements that might affect site usability;
• adequacy of fire and police protection;
• visibility, current usage and expandability; and
• potential impact on the neighborhood.

Costs factors:

• acquisition costs (sale/lease terms);
• costs specific to building design related to the specialty services offered (e.g., dental);
• cost of provisions for adequate water, sewerage and electricity;
• cost of providing natural gas, if required;
• cost of necessary site grading and/or fill;
• cost of drainage and protection against groundwater;
• unusual costs related to foundations;
• legal fees; and
• other miscellaneous costs, usually external to the site itself, e.g., shared costs of improving access roads.

In addition and supplemental to the foregoing factors, the Primary Care Centers Design and Construction guidance published by the Appalachian Regional Commission recommends the following factors be considered in determining a site and location:

Site and Location Factors:

• The minimum size site required for a particular building can be estimated by adding the following:
  1. Building footprint (gross square foot area of the first floor).
  2. Area required by zoning regulations for set backs (in the absence of zoning requirements, use the area of the building footprint).
  3. Area required for parking and driveways (for estimating purposes use 350 square feet per parking space, which includes circulation).
  4. Area for future expansion (as a minimum use one half the area of the building footprint).
  5. Area for septic tank and drain field or package treatment plant if a municipal system is not available. (The area required varies considerably depending upon percolation qualities of the soil and size of the center, but usually ranges between 500 square feet and 2,000 square feet.)

A sample computation of minimum site requirements for a 5,000 square-foot, one-story building with 30 parking spaces follows:

• Location of the facility is important and should be given careful consideration, recognizing that the choices are usually limited by availability and cost of land and availability of adequate water and sewer. If a central sewer system is not available, it will be necessary to provide a septic tank and drain field package treatment plant. These facilities will require county and/or state approval.
• Location near a hospital reduces commuting time between hospital and center and can facilitate access to specialists and ancillary services that might be available at the hospital. An area convenient to the majority of the population served by the primary care facility can be equally important. In rural areas it is desirable to be near a central location on a good road. Sites in noisy or unpleasant areas should be avoided.
• The site should be reasonably level and free from drainage problems. A soil analysis obtained early in the development process will identify any unusual foundation problems. Sites that have extensive drainage problems or require multi-level parking structures should be avoided if at all possible.
• Adequate parking is important. If possible, one parking space for each full-time equivalent staff position and two spaces for each examination or treatment room (medical and dental) should be provided.
• The entrance to the building should be conveniently accessible to the handicapped. Steps and ramps should be avoided if possible.
• A staff entrance should be provided so that staff can come and go without passing through the waiting room. This entrance can also be used for delivery of supplies and services.
• Exterior lighting should be provided in the parking area. Flood lights mounted on the building may be sufficient.

If you are interested in learning more about site selection criteria, space requirements, options for acquiring space, etc., your most immediate source of information will be the local people whom you have placed on your Site Selection Committee. Hopefully the Committee will include a local realtor, architect, and/or builder. More generic sources of information regarding ambulatory care facilities design and construction may be obtained from the publication department of the American Hospital Association (AHA) at http://www.aha.org and Medical Group Management Association (MGMA) at http://mgma.org. Another source of excellent guidance is contained within the publication entitled Primary Care Centers Design and Construction available from the Appalachian Regional Commission (ARC). A copy of this publication's Table of Contents is included as Exhibit 8-1. The ARC Web site is http://www.arc.gov and the agency may alternatively be contacted at (202) 884-7799 to request a copy.