Health Savings Accounts – An American Innovation in Health Insurance

INTRODUCTON – The term “health insurance” is commonly used in the United States to describe any program that helps pay for medical expenses, whether through privately purchased insurance, social insurance or a non-insurance social welfare program funded by the government. Synonyms for this usage include “health coverage,” “health care coverage” and “health benefits” and “medical insurance.” In a more technical sense, the term is used to describe any form of insurance that provides protection against injury or illness.

In America, the health insurance industry has changed rapidly during the last few decades. In the 1970’s most people who had health insurance had indemnity insurance. Indemnity insurance is often called fee-forservice. It is the traditional health insurance in which the medical provider (usually a doctor or hospital) is paid a fee for each service provided to the patient covered under the policy. An important category associated with the indemnity plans is that of consumer driven health care (CDHC). Consumer-directed health plans allow individuals and families to have greater control over their health care, including when and how they access care, what types of care they receive and how much they spend on health care services.

These plans are however associated with higher deductibles that the insured have to pay from their pocket before they can claim insurance money. Consumer driven health care plans include Health Reimbursement Plans (HRAs), Flexible Spending Accounts (FSAs), high deductible health plans (HDHps), Archer Medical Savings Accounts (MSAs) and Health Savings Accounts (HSAs). Of these, the Health Savings Accounts are the most recent and they have witnessed rapid growth during the last decade.

WHAT IS A HEALTH SAVINGS ACCOUNT?

A Health Savings Account (HSA) is a tax-advantaged medical savings account available to taxpayers in the United States. The funds contributed to the account are not subject to federal income tax at the time of deposit. These may be used to pay for qualified medical expenses at any time without federal tax liability.

Another feature is that the funds contributed to Health Savings Account roll over and accumulate year over year if not spent. These can be withdrawn by the employees at the time of retirement without any tax liabilities. Withdrawals for qualified expenses and interest earned are also not subject to federal income taxes. According to the U.S. Treasury Office, ‘A Health Savings Account is an alternative to traditional health insurance; it is a savings product that offers a different way for consumers to pay for their health care.

HSA’s enable you to pay for current health expenses and save for future qualified medical and retiree health expenses on a tax-free basis.’ Thus the Health Savings Account is an effort to increase the efficiency of the American health care system and to encourage people to be more responsible and prudent towards their health care needs. It falls in the category of consumer driven health care plans.

Origin of Health Savings Account

The Health Savings Account was established under the Medicare Prescription Drug, Improvement, and Modernization Act passed by the U.S. Congress in June 2003, by the Senate in July 2003 and signed by President Bush on December 8, 2003.

Eligibility –

The following individuals are eligible to open a Health Savings Account –

– Those who are covered by a High Deductible Health Plan (HDHP).
– Those not covered by other health insurance plans.
– Those not enrolled in Medicare4.

Also there are no income limits on who may contribute to an HAS and there is no requirement of having earned income to contribute to an HAS. However HAS’s can’t be set up by those who are dependent on someone else’s tax return. Also HSA’s cannot be set up independently by children.

What is a High Deductible Health plan (HDHP)?

Enrollment in a High Deductible Health Plan (HDHP) is a necessary qualification for anyone wishing to open a Health Savings Account. In fact the HDHPs got a boost by the Medicare Modernization Act which introduced the HSAs. A High Deductible Health Plan is a health insurance plan which has a certain deductible threshold. This limit must be crossed before the insured person can claim insurance money. It does not cover first dollar medical expenses. So an individual has to himself pay the initial expenses that are called out-of-pocket costs.

In a number of HDHPs costs of immunization and preventive health care are excluded from the deductible which means that the individual is reimbursed for them. HDHPs can be taken both by individuals (self employed as well as employed) and employers. In 2008, HDHPs are being offered by insurance companies in America with deductibles ranging from a minimum of $1,100 for Self and $2,200 for Self and Family coverage. The maximum amount out-of-pocket limits for HDHPs is $5,600 for self and $11,200 for Self and Family enrollment. These deductible limits are called IRS limits as they are set by the Internal Revenue Service (IRS). In HDHPs the relation between the deductibles and the premium paid by the insured is inversely propotional i.e. higher the deductible, lower the premium and vice versa. The major purported advantages of HDHPs are that they will a) lower health care costs by causing patients to be more cost-conscious, and b) make insurance premiums more affordable for the uninsured. The logic is that when the patients are fully covered (i.e. have health plans with low deductibles), they tend to be less health conscious and also less cost conscious when going for treatment.

Opening a Health Savings Account

An individual can sign up for HSAs with banks, credit unions, insurance companies and other approved companies. However not all insurance companies offer HSAqualified health insurance plans so it is important to use an insurance company that offers this type of qualified insurance plan. The employer may also set up a plan for the employees. However, the account is always owned by the individual. Direct online enrollment in HSA-qualified health insurance is available in all states except Hawaii, Massachusetts, Minnesota, New Jersey, New York, Rhode Island, Vermont and Washington.

Contributions to the Health Savings Account

Contributions to HSAs can be made by an individual who owns the account, by an employer or by any other person. When made by the employer, the contribution is not included in the income of the employee. When made by an employee, it is treated as exempted from federal tax. For 2008, the maximum amount that can be contributed (and deducted) to an HSA from all sources is:
$2,900 (self-only coverage)
$5,800 (family coverage)

These limits are set by the U.S. Congress through statutes and they are indexed annually for inflation. For individuals above 55 years of age, there is a special catch up provision that allows them to deposit additional $800 for 2008 and $900 for 2009. The actual maximum amount an individual can contribute also depends on the number of months he is covered by an HDHP (pro-rated basis) as of the first day of a month. For eg If you have family HDHP coverage from January 1,2008 until June 30, 2008, then cease having HDHP coverage, you are allowed an HSA contribution of 6/12 of $5,800, or $2,900 for 2008. If you have family HDHP coverage from January 1,2008 until June 30, 2008, and have self-only HDHP coverage from July 1, 2008 to December 31, 2008, you are allowed an HSA contribution of 6/12 x $5,800 plus 6/12 of $2,900, or $4,350 for 2008. If an individual opens an HDHP on the first day of a month, then he can contribute to HSA on the first day itself. However, if he/she opens an account on any other day than the first, then he can contribute to the HSA from the next month onwards. Contributions can be made as late as April 15 of the following year. Contributions to the HSA in excess of the contribution limits must be withdrawn by the individual or be subject to an excise tax. The individual must pay income tax on the excess withdrawn amount.

Contributions by the Employer

The employer can make contributions to the employee’s HAS account under a salary reduction plan known as Section 125 plan. It is also called a cafeteria plan. The contributions made under the cafeteria plan are made on a pre-tax basis i.e. they are excluded from the employee’s income. The employer must make the contribution on a comparable basis. Comparable contributions are contributions to all HSAs of an employer which are 1) the same amount or 2) the same percentage of the annual deductible. However, part time employees who work for less than 30 hours a week can be treated separately. The employer can also categorize employees into those who opt for self coverage only and those who opt for a family coverage. The employer can automatically make contributions to the HSAs on the behalf of the employee unless the employee specifically chooses not to have such contributions by the employer.

Withdrawals from the HSAs

The HSA is owned by the employee and he/she can make qualified expenses from it whenever required. He/She also decides how much to contribute to it, how much to withdraw for qualified expenses, which company will hold the account and what type of investments will be made to grow the account. Another feature is that the funds remain in the account and role over from year to year. There are no use it or lose it rules. The HSA participants do not have to obtain advance approval from their HSA trustee or their medical insurer to withdraw funds, and the funds are not subject to income taxation if made for ‘qualified medical expenses’. Qualified medical expenses include costs for services and items covered by the health plan but subject to cost sharing such as a deductible and coinsurance, or co-payments, as well as many other expenses not covered under medical plans, such as dental, vision and chiropractic care; durable medical equipment such as eyeglasses and hearing aids; and transportation expenses related to medical care. Nonprescription, over-the-counter medications are also eligible. However, qualified medical expense must be incurred on or after the HSA was established.

Tax free distributions can be taken from the HSA for the qualified medical expenses of the person covered by the HDHP, the spouse (even if not covered) of the individual and any dependent (even if not covered) of the individual.12 The HSA account can also be used to pay previous year’s qualified expenses subject to the condition that those expenses were incurred after the HSA was set up. The individual must preserve the receipts for expenses met from the HSA as they may be needed to prove that the withdrawals from the HSA were made for qualified medical expenses and not otherwise used. Also the individual may have to produce the receipts before the insurance company to prove that the deductible limit was met. If a withdrawal is made for unqualified medical expenses, then the amount withdrawn is considered taxable (it is added to the individuals income) and is also subject to an additional 10 percent penalty. Normally the money also cannot be used for paying medical insurance premiums. However, in certain circumstances, exceptions are allowed.

These are –

1) to pay for any health plan coverage while receiving federal or state unemployment benefits.
2) COBRA continuation coverage after leaving employment with a company that offers health insurance coverage.
3) Qualified long-term care insurance.
4) Medicare premiums and out-of-pocket expenses, including deductibles, co-pays, and coinsurance for: Part A (hospital and inpatient services), Part B (physician and outpatient services), Part C (Medicare HMO and PPO plans) and Part D (prescription drugs).

However, if an individual dies, becomes disabled or reaches the age of 65, then withdrawals from the Health Savings Account are considered exempted from income tax and additional 10 percent penalty irrespective of the purpose for which those withdrawals are made. There are different methods through which funds can be withdrawn from the HSAs. Some HSAs provide account holders with debit cards, some with cheques and some have options for a reimbursement process similar to medical insurance.

Growth of HSAs

Ever since the Health Savings Accounts came into being in January 2004, there has been a phenomenal growth in their numbers. From around 1 million enrollees in March 2005, the number has grown to 6.1 million enrollees in January 2008.14 This represents an increase of 1.6 million since January 2007, 2.9 million since January 2006 and 5.1 million since March 2005. This growth has been visible across all segments. However, the growth in large groups and small groups has been much higher than in the individual category. According to the projections made by the U.S. Treasury Department, the number of HSA policy holders will increase to 14 million by 2010. These 14 million policies will provide cover to 25 to 30 million U.S. citizens.

In the Individual Market, 1.5 million people were covered by HSA/HDHPs purchased as on January 2008. Based on the number of covered lives, 27 percent of newly purchased individual policies (defined as those purchased during the most recent full month or quarter) were enrolled in HSA/HDHP coverage. In the small group market, enrollment stood at 1.8 million as of January 2008. In this group 31 percent of all new enrollments were in the HSA/HDHP category. The large group category had the largest enrollment with 2.8 million enrollees as of January 2008. In this category, six percent of all new enrollments were in the HSA/HDHP category.

Benefits of HSAs

The proponents of HSAs envisage a number of benefits from them. First and foremost it is believed that as they have a high deductible threshold, the insured will be more health conscious. Also they will be more cost conscious. The high deductibles will encourage people to be more careful about their health and health care expenses and will make them shop for bargains and be more vigilant against excesses in the health care industry. This, it is believed, will reduce the growing cost of health care and increase the efficiency of the health care system in the United States. HSA-eligible plans typically provide enrollee decision support tools that include, to some extent, information on the cost of health care services and the quality of health care providers. Experts suggest that reliable information about the cost of particular health care services and the quality of specific health care providers would help enrollees become more actively engaged in making health care purchasing decisions. These tools may be provided by health insurance carriers to all health insurance plan enrollees, but are likely to be more important to enrollees of HSA-eligible plans who have a greater financial incentive to make informed decisions about the quality and costs of health care providers and services.

It is believed that lower premiums associated with HSAs/HDHPs will enable more people to enroll for medical insurance. This will mean that lower income groups who do not have access to medicare will be able to open HSAs. No doubt higher deductibles are associated with HSA eligible HDHPs, but it is estimated that tax savings under HSAs and lower premiums will make them less expensive than other insurance plans. The funds put in the HSA can be rolled over from year to year. There are no use it or lose it rules. This leads to a growth in savings of the account holder. The funds can be accumulated tax free for future medical expenses if the holder so desires. Also the savings in the HSA can be grown through investments.

The nature of such investments is decided by the insured. The earnings on savings in the HSA are also exempt from income tax. The holder can withdraw his savings in the HSA after turning 65 years old without paying any taxes or penalties. The account holder has complete control over his/her account. He/She is the owner of the account right from its inception. A person can withdraw money as and when required without any gatekeeper. Also the owner decides how much to put in his/her account, how much to spend and how much to save for the future. The HSAs are portable in nature. This means that if the holder changes his/her job, becomes unemployed or moves to another location, he/she can still retain the account.

Also if the account holder so desires he can transfer his Health Saving Account from one managing agency to another. Thus portability is an advantage of HSAs. Another advantage is that most HSA plans provide first-dollar coverage for preventive care. This is true of virtually all HSA plans offered by large employers and over 95% of the plans offered by small employers. It was also true of over half (59%) of the plans which were purchased by individuals.

All of the plans offering first-dollar preventive care benefits included annual physicals, immunizations, well-baby and wellchild care, mammograms and Pap tests; 90% included prostate cancer screenings and 80% included colon cancer screenings. Some analysts believe that HSAs are more beneficial for the young and healthy as they do not have to pay frequent out of pocket costs. On the other hand, they have to pay lower premiums for HDHPs which help them meet unforeseen contingencies.

Health Savings Accounts are also advantageous for the employers. The benefits of choosing a health Savings Account over a traditional health insurance plan can directly affect the bottom line of an employer’s benefit budget. For instance Health Savings Accounts are dependent on a high deductible insurance policy, which lowers the premiums of the employee’s plan. Also all contributions to the Health Savings Account are pre-tax, thus lowering the gross payroll and reducing the amount of taxes the employer must pay.

Criticism of HSAs

The opponents of Health Savings Accounts contend that they would do more harm than good to America’s health insurance system. Some consumer organizations, such as Consumers Union, and many medical organizations, such as the American Public Health Association, have rejected HSAs because, in their opinion, they benefit only healthy, younger people and make the health care system more expensive for everyone else. According to Stanford economist Victor Fuchs, “The main effect of putting more of it on the consumer is to reduce the social redistributive element of insurance.

Some others believe that HSAs remove healthy people from the insurance pool and it makes premiums rise for everyone left. HSAs encourage people to look out for themselves more and spread the risk around less. Another concern is that the money people save in HSAs will be inadequate. Some people believe that HSAs do not allow for enough savings to cover costs. Even the person who contributes the maximum and never takes any money out would not be able to cover health care costs in retirement if inflation continues in the health care industry.

Opponents of HSAs, also include distinguished figures like state Insurance Commissioner John Garamendi, who called them a “dangerous prescription” that will destabilize the health insurance marketplace and make things even worse for the uninsured. Another criticism is that they benefit the rich more than the poor. Those who earn more will be able to get bigger tax breaks than those who earn less. Critics point out that higher deductibles along with insurance premiums will take away a large share of the earnings of the low income groups. Also lower income groups will not benefit
substantially from tax breaks as they are already paying little or no taxes. On the other hand tax breaks on savings in HSAs and on further income from those HSA savings will cost billions of dollars of tax money to the exchequer.

The Treasury Department has estimated HSAs would cost the government $156 billion over a decade. Critics say that this could rise substantially. Several surveys have been conducted regarding the efficacy of the HSAs and some have found that the account holders are not particularly satisfied with the HSA scheme and many are even ignorant about the working of the HSAs. One such survey conducted in 2007 of American employees by the human resources consulting firm Towers Perrin showed satisfaction with account based health plans (ABHPs) was low. People were not happy with them in general compared with people with more traditional health care. Respondants said they were not comfortable with the risk and did not understand how it works.

According to the Commonwealth Fund, early experience with HAS eligible high-deductible health plans reveals low satisfaction, high out of- pocket costs, and cost-related access problems. Another survey conducted with the Employee Benefits Research Institute found that people enrolled in HSA-eligible high-deductible health plans were much less satisfied with many aspects of their health care than adults in more comprehensive plans People in these plans allocate substantial amounts of income to their health care, especially those who have poorer health or lower incomes. The survey also found that adults in high-deductible health plans are far more likely to delay or avoid getting needed care, or to skip medications, because of the cost. Problems are particularly pronounced among those with poorer health or lower incomes.

Political leaders have also been vocal about their criticism of the HSAs. Congressman John Conyers, Jr. issued the following statement criticizing the HSAs “The President’s health care plan is not about covering the uninsured, making health insurance affordable, or even driving down the cost of health care. Its real purpose is to make it easier for businesses to dump their health insurance burden onto workers, give tax breaks to the wealthy, and boost the profits of banks and financial brokers. The health care policies concocted at the behest of special interests do nothing to help the average American. In many cases, they can make health care even more inaccessible.” In fact a report of the U.S. governments Accountability office, published on April 1, 2008 says that the rate of enrollment in the HSAs is greater for higher income individuals than for lower income ones.

A study titled “Health Savings Accounts and High Deductible Health Plans: Are They an Option for Low-Income Families? By Catherine Hoffman and Jennifer Tolbert which was sponsored by the Kaiser Family Foundation reported the following key findings regarding the HSAs:

a) Premiums for HSA-qualified health plans may be lower than for traditional insurance, but these plans shift more of the financial risk to individuals and families through higher deductibles.
b) Premiums and out-of-pocket costs for HSA-qualified health plans would consume a substantial portion of a low-income family’s budget.
c) Most low-income individuals and families do not face high enough tax liability to benefit in a significant way from tax deductions associated with HSAs.
d) People with chronic conditions, disabilities, and others with high cost medical needs may face even greater out-of-pocket costs under HSA-qualified health plans.
e) Cost-sharing reduces the use of health care, especially primary and preventive services, and low-income individuals and those who are sicker are particularly sensitive to cost-sharing increases.
f) Health savings accounts and high deductible plans are unlikely to substantially increase health insurance coverage among the uninsured.

Choosing a Health Plan

Despite the advantages offered by the HSA, it may not be suitable for everyone. While choosing an insurance plan, an individual must consider the following factors:

1. The premiums to be paid.
2. Coverage/benefits available under the scheme.
3. Various exclusions and limitations.
4. Portability.
5. Out-of-pocket costs like coinsurance, co-pays, and deductibles.
6. Access to doctors, hospitals, and other providers.
7. How much and sometimes how one pays for care.
8. Any existing health issue or physical disability.
9. Type of tax savings available.

The plan you choose should according to your requirements and financial ability.

BIBLIOGRAPHY

1 Questions and Answers about Health Insurance- A Consumer Guide’ published jointly by the Agency for Healthcare Research and Quality (AHRQ)and America’s Health Insurance Plans (AHIP)
2 http://www.en.wikipedia.org/wiki/Health_savings_account
3 2002 AHIP Survey of Health Insurance Plans
4 “How High Is Too High? Implications of High-Deductible Health Plans” Davis, Karen; Michelle Doty and Alice Ho. The Commonwealth Fund, April 2005
5 http://www.fdhc.state.fl.us/schs/pdf/hsa_tri-fold_brochure.pdf
6 HSA/HDHP CENSUS 2008 by Hannah Yoo, Center for Policy and Research, America’s Health Insurance Plans
7″HEALTH SAVINGS ACCOUNTS Early Enrollee Experiences with Accounts and Eligible Health Plans” John E. Dicken Director, Health Care.
8 Thomas Wilder and Hannah Yoo, “A Survey of Preventive Benefits in Health Savings Account (HSA)Plans, July 2007,” America’s Health Insurance Plans, November 2007
9 Gladwell, Malcolm, “The Moral Hazard Myth”, The New Yorker (29-08-2005)
10 2008 Benchmark Survey HAS Bank
11. Employer Health Benefits 2007 Annual Survey, Kaiser Family Foundation
12. Health Savings Accounts and High Deductible Health Plans: Are They An Option for Low-Income Families?Catherine Hoffman and Jennifer Tolbert for Kaiser Family Foundation, October 2006
13. Medicare Prescription Drug, Improvement, and Modernization Act of 2003

Vacation Rentals and Holiday Home Rentals – "Tips For Renting"

So you’re planning the holidays, you fancy something in the sun, but where to go? Who is coming? How many?
Will we rent a luxury condo or house instead of staying in a hotel? Well you can make big savings by taking a Villa. Plus, you’ll have more space and privacy to relax and enjoy your home away from home. Renting a vacation home is an especially smart choice if you’re traveling with a group of friend or with kids.

Here are some tips to help you get the biggest bang for your buck.

1. Once you choose a destination.
If you’re looking for sensational savings your best bet is to choose a destination where there are a lot of holiday rentals on the market, keeping prices competitive. You can find some of the best bargains on vacation home rentals online if you know what to ask about and how to protect yourself as a renter. Don’t be shy contact the owner and ask for a deal.

2. Comparison sites- way to go!
Now it’s easier than ever to comparison shop when you’re looking to save on a vacation home rental. You can find some of the best rental home listings the net has to offer on sites like holiday121 and other consolidator sites like these. These are referral sites not booking site and you can check out many homes at the same time to get the best prices and most suitable dates and keep a record of sites visited.

3. Don’t send money.
When renting a vacation home, never send anyone money it’s a bad idea. Pay by credit card or PayPal where you have some come back.
Ask for references, and check out their Web site and their track record. Read their reviews! Read the fine print. Is there a cancellation policy? What if you have to leave early? Does it stipulate when you will get your breakage deposit back? Spend the time up front checking things out so you won’t have any hassles later.

4. Know exactly what’s included.
When you book a rental home for your holidays it’s a short term rental and everything should be included, if there are extras like pool heat, these will be stipulated on the invoice.
Most rental homes will say “everything’s included,” but you want to double-check to be sure that there are no hidden surcharges there should not be any.
If utilities, Internet and cable are included, does this mean the property has Wi-Fi and high-speed Internet? Is it basic cable or premium? If electricity is paid is there a cap? Many properties will say they include utilities, electricity and gas and then the fine print says it’s included, up to the first $200.
Recommendation; don’t touch a short term rental that is not all inclusive.

5. Who is the local management company?
Ask who has the local management of the property these are a very important part of the service and backup. Your rental contract should include who to call if your dishwasher breaks or there’s some other problem with the property. It should also state a time frame for fixing any major problems. You don’t want to rent a home and have the hot water heater conk out and end up with cold showers for two week. The information should also be posted in a contact book inside the property. Make sure you have a phone number and email address of the contact and if possible get a second person as a backup.

6. Is the home family friendly?
If you’re traveling with kids, make sure the property you rental is family friendly. Check the bed configurations. If you have three kids and the guest room only has a king-sized bed you could be in trouble. Does the pool have an alarm? (Toddler safety)
Also make sure you see lots pictures of the home. Do you really want to rent a place with a white couch and fancy décor if your 3-year-old still thinks it is fun to color on everything in sight? Make sure the home you’re renting fits your family’s needs so you’re all comfortable. What about the location? Where is the house what are the local amenities? Is it close to the attractions?

7. Can you bring a pet?
Some vacation rentals accept pets, but they may have a size limit. Some folks would not like to rent a property for their family that had the possibility of a pet staying in with previous guests in the home, unhygienic, so if that may be a problem eliminate pet friendly from your search.

8. Is a refund available if you leave early?
If you think you may want or need to leave early, check your contract to see if you’re eligible for a partial refund. Most vacation rentals are for a specific time period and don’t offer refunds because that leaves the homeowner in a lurch with no time to rent to someone else. Know going in what the rules are so there are no unpleasant surprises.

9. Pick a house that most suits your needs.
Keep in mind when you’re renting a vacation home you’re renting a property that’s individually owned. This isn’t a hotel where if you don’t like what you have you can get something else. Once you book and pay your deposit for a specific property, that’s the property you’re getting, so make sure it’s exactly what you want. Ask if reviews from other renters are available; also remember you get what you pay for so contact the owner. While scoring a good deal is the goal, if it’s too cheap there’s probably a reason check it out. Sometimes the cheapest price is not the best value.

10. Book early.
Avoid disappointment; there are certain times of the year when the villa rentals are on fire, so book early. Also you might look at the availability on the owners web site and pick a slightly out of season time, which brings me back to point one, don’t be shy contact the owner and ask for a deal. A last point to help is a lot of vacation rental owners have links to car rental and cheap flights sites or attraction ticket sites. Try and do a package deal for all three or four services. Good luck!!

Three Reasons to Hire a Car on Your Holidays

If you are planning to arrange transportation in Portugal, then you will find many options for you. However, the best transportation medium is to have car hire in Portugal. Of course, you can get other public and private transport option, but in most of the situation you will find that you are doing the best deal by going for car hire in Portugal. So, let’s see the three most common reasons why you should go for car rental in Portugal.

  • You will get best deals in terms of cost: Car rental is better if you have a travel plan spanning over different spots of city. For example, you are a tourist or have come for visiting places like coast lines at Algarve or different spots in Lisbon or Faro; then a car hire in Portugal make sense. Instead of taking different vehicles from one spot to another, a car rental for the required stretch of distance or time will give you economical advantage. Some times car hire companies will have different discounts or package for different tourist spots, too. This may depend on the seasons, when the passengers going for car rental in Portugal may be less. So, watch out for these discounts and it will prove to be a best deal for you. In case, you are a local there also, a car hire in Portugal will offer a relatively economic option for you, especially in case you are looking out for convenience too.
  • It provides a real comfort: Car rental is always very comfortable as compared to other public and private transport. The same way car hire in Portugal will take care about your comfort, while traveling. It is spacious and you need not worry about luggage too. It sees about your own comfort, all because of the reason that it has been hired personally for you. This makes a very economical comfortable option for you.
  • Takes care about your urgency, time schedule, etc: One of the reasons why people prefer for car hire in Portugal and elsewhere also is because of convenience with regard to your time schedule and plan. For example, while traveling you needs to stop over somewhere for shopping for a bit more time, you are free to do that without worrying for you being getting delayed. In case, you are planning to go for airport quickly, you can easily do so by taking an alternative way, if the main road has some traffic jam. In case of Portugal, you will always like to do that seeing all the scenic spots you will find at Algarve beach or stunning places at Faro.

Researching and Booking Hotels Online

When planning a holiday, it’s always difficult to know where to stay: how do you pick a hotel you’ve never experienced in an area of a city you might never have visited before? Staying in the right place is a key part of your trip; having comfortable surroundings and being in the right location is crucial for both the holidaymaker and the business traveler.

There are so many sites that offer online travel advice, its hard to know where to start! But next time you’re searching for a hotel to stay in, be sure to check out the following:

Wikitravel

Wikitravel is a great starting point for any traveller. The site provides information from a traveler’s perspective and offers useful advice in relation to where to eat and what to do in any given area. Larger cities are split into smaller districts, and on choosing which district you want to stay in, you are offered hotel options to suit your style and budget.

Expedia

Expedia has a directory of over 80,000 places to stay world-wide and can help you narrow down your search and find the right accommodation. It’s worth remembering that choosing a hotel on price alone is never a great idea. Hotels that are further away from attractions and amenities are usually the cheapest, but as location is a very important factor of any holiday it might be worth paying a little more to be located centrally. The handy map feature on expedia allows you to see exactly where the available rooms are located, letting you weigh up price against location.

Venere

Venere lets you filter your search results down to help pinpoint the perfect hotel for you. The filters include budget, type of accommodation and star rating, although generally photos give a better indicator of just how good a hotel is. When looking at photos of rooms, it’s worth cross checking these with recent reviews of the hotel, just to ensure that the photos are not only recent, but also a genuine representation of the room you will receive upon your arrival.

TripAdvisor

One of the best places to find customer reviews online is TripAdvisor, which has over 75 million reviews, tips and opinions from every type of traveller from around the world. TripAdvisor gives travelers the opportunity to rate hotels, share photos and videos and connect socially with other travellers.

Booking.com

Booking.com is the leading online travel agent and attracts over 30 million unique visitors each month. Offering over 253,441 hotels in 178 countries, the site aims to help travelers discover the best places to stay. Targeted at business and leisure travelers alike, the site scores hotels based on user reviews, which are broken down into categories such as comfort, location, value for money etc.. Hotels can also be filtered by the type of person who left the review – such as families with young children, solo travellers or large groups.

When it comes to booking your chosen hotel, you might think that online travel agents offer the best deals, but this isn’t necessarily the case. Booking direct with a hotel presents many advantages:

– You may be able to find exclusive promotions which aren’t offered on travel agent sites

– Some hotels offer frequent guest points and frequent flyers miles

– Hotels provide guest recognition, meaning the hotel will already know your likes and dislikes if you’ve stayed there before

– Having a direct point of contact at a hotel makes it easier to amend or cancel bookings

– Booking verification is instant as there’s no third party to confuse matters.

So next time you’re looking for a hotel, be it for business or pleasure, remember that while online travel agents and travel review sites can act as a valuable source of information, more often than not you’re better off booking via the hotel directly.

Cheap Car Insurance and Car Safety – Use of Cellphones While Driving

There have always been debates about what constitutes distraction or different levels of distraction whilst driving a car, ranging from listening to the radio, having rows with kids to generally having a lack of awareness or understanding of road sense as to what is going on around you.

Cellphones and the use of cellphones whilst driving have taken this debate to a new level. It is simply not an academic debate any more since the use of cellphones both for making and receiving calls and for sending and receiving text messages or SMS messages has become widespread in most countries in the world.

Cellphones have come a long way since the first one appeared in the James Bond film from Russia with Love, and are now considered a routine part of most people’s drivers experience. Car manufacturers are increasingly building and integrating cell phone capabilities into the vehicles themselves, either by way of Bluetooth technology or other sorts of technological adaptations of cellphones.

When cellphones first became widespread they were often known as car phone’s, because that was where they were mostly used. Because of the size of the car phone it meant that most people would only use them when the car was stationary and would consciously make an effort to pull over or stop in a safe place before answering all receiving calls. At cellphones have changed in size and capability to reverse became true. More people began to find it easy and often necessary to make or receive calls during the course of a journey and subsequently do not think of it as being risky or distracting behaviour.

After a while governments began to realise both the normalisation of using a cellphone whilst driving, and the inherent dangers and risks associated with such. Many states and governments introduced laws that made holding a cellphone whilst making or receiving a call a criminal offence. The use of Bluetooth technology and other types technology allowed drivers to make and receive what are known as hands-free calls which were deemed to be safer and less distracting and physically having to hold a cellphone handset in the hand whilst driving.

That belief that hands-free driving is safer may or may not be true. The reality is that in most places it is legal but has almost been superseded by a bigger problem, that of sending and receiving text messages or SMS messages. This is a widespread and incredibly dangerous practice, not least because it involves the use of one or both hands whilst driving, but it also requires the driver to look at the screen of the cellphone whilst sending or receiving text messages rather than looking at the road around them to see what is going on.

The United States government has done research that shows that the use of a cellphone whilst driving can effectively be as distracting or have a similar effect to that of the driver being intoxicated was driving. It is an incredibly serious issue and one which most legislators have in reality given lip service to. The enormity of what it means in terms of potential fatalities or accidents is huge. In terms of car safety the any real safe use of a cellphone is when the car is stationary and effectively off-road so the driver does not have to concentrate on what is going on around them at the same time. In terms of car insurance there are a number of scenarios where the driver of the car, if involved in a fatality or accident that occurred whilst they were using a cellphone improperly, could have their car insurance compromised.

How To Properly Remove A Bumper Sticker and Blend the Paint to Match

No matter what your reasons may be you’ve decided its’ time to remove that old faded bumper sticker from your vehicle. Lucky for you in just a few minutes and with a small amount of effort your car can be bumper sticker free. This process can be repeated for just about any type of adhesive stuck to your vehicle. It can be used to remove inspection stickers from windows, or vinyl lettering/vinyl graphics from the vehicle as well. The most important part is to be very patient and not try to rush through any steps. All of the steps below should be completed in a garage, under a carport or during dawn/dusk to provide as much time as possible before the adhesive remover dries on the car.

What You Will Need:

Razor Blade (Single Sided Square Blade Recommended)

Citrus Based Adhesive Solvent (Goo Gone Automotive Cleaner Recommended)

Automotive Paint Safe Bug Brush (Can be purchased at Walmart, or any auto parts store)

Microfiber Towels

Wax

Compound

Applicators

STEP #1: Take your razor blade and carefully slide the edge of the blade under a corner of the sticker. With the edge of the razor blade under the sticker gently tease up the corner of the sticker.

STEP #2: Grab the freed corner of the sticker and slowly pull the sticker in the direction of the remaining sticker. NOTE: If the sticker becomes too difficult to pull without tearing, apply your citrus based adhesive solvent to the adhesive sticker backing during this step. The solvent will loosen the adhesive, making it easier to remove the sticker. It is recommended to wait at least one minute to allow the solvent to penetrate and break down the adhesive.

STEP #3: Once you have removed the entire sticker, there will still be bumper sticker adhesive left behind. Now apply the citrus based adhesive remover to your automotive paint safe bug brush. Using the bug brush, apply some citrus based adhesive remover to the remaining adhesive on the vehicle in a circular motion. NOTE: This step may will most likely have to be repeated in order to remove all the adhesive from the vehicle. To ensure everything is removed, run your hand across the area once dried. Any remaining sticker glue will create a rough/sticky feeling. If there is still some leftover then repeat step #3. If there is no residue or leftover you may proceed to step #4.

STEP #4: Remove the excess adhesive remover with your microfiber towel.

Note: There will be some slight scuff/mar marks as well as a discoloration of the paint depending on how long the bumper sticker was on the car. This will need to be removed by compounding and polishing the area to smooth out any blemishes and blend the clear coat to match the rest of the bumper.

STEP #5: Now that the bumper sticker has been removed and all adhesive cleaned up it is time to make it look like the rest of the bumper. Follow the steps on how to properly compound and polish a car to remove light swirls and scratches.

STEP#6: Inspect the area where the sticker was to ensure it is satisfactory. Remember to apply a couple coats of wax, since it has been a long time since this portion of the bumper saw any.

Removing a bumper sticker can seem like an insurmountable task, and often people will give up because of the difficulty. With a little patience, the right tools and know how anyone can learn how to properly remove a bumper sticker without any blemishes to the paint.

Quick Finance – Caveat Loans And Bridging Finance

Short term loans help people lessen their immediate money troubles, because of increasing everyday expenses and no sufficient income to meet the requirements. These loans by and large come in a shape of payday loans, in that you can obtain immediate cash with the settlement time between two and three weeks. Lots of lenders in Australia offer their service online that let you submit an application for the finance, 24 hours a day and 7 days a week.

If you need fast money, then a caveat loan, short term loan or bridging finance from any Australian finance Centre can help.

Caveat loans

Fundamentally, caveat loans are all about when lenders offer the borrower fast money, in return for their property as defense for the finance.

The submission of applications for these loans is extremely quick, and it is likely to be short term from approximately one month to four months. Usually the borrower can get the money inside 24 hours after the request has been launched, and in the majority of cases, having a bad credit documentation does not have an effect on your possibility of successfully achieving it. In other words, these loans are finance for property.

The reason caveat loans are provided for assets is since the borrower have to secure an asset against it, and the majority of the time, the assets consists of realty properties or vehicles, as other kinds of assets are usually not acknowledged to be a defense for such loans.

Bridging Finance

By explanation, Bridging Finance is a short-term loan used to buy business property.

This is something that can come in very helpful, conditional on your particular circumstances. There are two major points that you need to think about before you choose a Bridging Finance package, your wants and the condition of the property market.

One of the main benefits of Bridging Finance is that it will let you close on a property and buy a new property before you get rid of your existing one. You will need to assess your present situation to decide if your wants give good reason for taking on this sort of finance.

Paying off your Bridging Loan at the ending of the term usually depends on your capacity to sell your existing property. If it is not sold in the obligatory time, then you will have to pay the existing loan on your present property, your new property and the newly transformed Bridge Finance, too. If you think that this might be the likelihood then be sure to take a package that can be changed to business Loans if the need comes up. Or else, you might have to come up with the complete finance amount at the conclusion of the funding time.

Legal Requirements For Internet Marketing

What is required to do business on-line? How complex is it to start and run an Internet business opportunity?

Unfortunately, the answer is that it depends. An on-line retail business can have complicated legal requirements associated with it like licensing, sales tax collection and reporting regulations.

On the other hand an Internet marketing business can be a very simple and direct path to follow to own a web based entrepreneurial activity.

For the purposes of this article, let’s examine the world of affiliate marketing since it can produce an income stream with minimal up front costs and very little regulation.

Representing the products of others requires no stock, no shipping, no sales tax issues and no reporting requirements.

Products are offered and sold through independent entities like Click Bank where any affiliate marketer can register, pick products to market and collect commissions.

Under such circumstances, the producer is responsible for product shipping and the Click Bank like operation processes the sale for the customer as well as sends out the commission to the marketer along with the profit to the producer.

The Click Banks keep all of the necessary records of the transactions, issue the checks or wires and provide the year end reporting for tax purposes. In other words, much of the busy work required of any small business person is supplied basically free of charge to the marketer. Hard to beat that kind of deal.

At the end of the day, there is not much required of the business person who operates as the affiliate marketer. However, there is some wisdom in doing the following.

To be in business, be a business. Form an entity of some type. You can choose to be a Sole Proprietor or even a Corporation. The details of such choices are not to be addressed here but it is easy enough to research the pros and cons of each as well as get advice from professionals like a CPA.

Entity formation has a lot to do with paying state and federal income taxes which, as we all know, are legally unavoidable. When registering with the Click Bank type operations a marketer is required to supply either their social security number or the tax ID number of their company. There is no escaping the long arm of the tax man since income will be reported for you.

Beyond that there is little else the law requires other than the possibility of a business license that your local government might want. That can easily be checked out by a call to your local Chamber of Commerce.

Thus affiliate marketing can get you into business for very little up front expense and can begin generating income almost immediately. More significantly, as you become a better marketer and expand the number of products you represent, that income stream can grow exponentially.

Because the trend in business start ups is increasingly toward doing business on-line, it would seem that the smart and easy way to launch would be with affiliate marketing. It represents the classic low risk, high reward business model that most every business person seeks.

Beyond that, it is the kind of business that can be started in one’s spare time so that current income sources can remain undisturbed, at least in the short run. Should the affiliate marketing business grow to the point of providing a sustainable income, it can than become a full time focus.

With little legal red tape to deal with and not much investment required, affiliate marketing provides the first and arguably the most important step into the world of doing business on the Internet. The link below is provided to showcase one such first step opportunity. You are invited to take the time to review the world of being an affiliate marketer.

After all, it might just be a glimpse into the future of your own on-line business.

Home Treatment For Hemorrhoids – Best Uncategorized Remedies

Hemorrhoids, also called piles that are normally present in the veins of anus and rectum. In hemorrhoids the veins become swollen and inflamed. The people whose age is 45 to 65 are the most sufferers of this disease. Hemorrhoids are defined as in different forms. Internal hemorrhoids occurs inside the anal cavity generally cause painless bleeding at the end of bowel movement. In this case one should consult a experience physician that can start the appropriate medication.

As the symptoms of Hemorrhoids you may get sensation of fullness, usually described as feeling the urge to have a bowel movement even when there is no stool. In the prolapsed hemorrhoids you may get acute pain, itching, and irritation around the anus. This kind of hemorrhoid occurs at the outside the anus or can be caused when a blood clot develops or the hemorrhoid becomes twisted. In this condition you will get painful lumps or swelling around the anus. This condition may be serious and should be treated first.

External hemorrhoids occur at the outside of anus which often felt as a bulge in the anus. Although this kind of hemorrhoid may be painful. This type of hemorrhoids causes some critical symptoms. When you got spots of blood on the toilet paper and have pain during bowel movements, then you should think that you may get hemorrhoids and start its medication. As a treatment you may start hemorrhoid home treatment.

As the home remedy of hemorrhoids you may need a day to take pressure off inflamed, irritated, veins. If you are pregnant then it will be helpful to lie on your side wherever if you are not pregnant and want to sleep on the stomach with a pillow. It will help in decreasing swelling of hemorrhoids. As a home remedy of hemorrhoids you should wear cotton underwear to prevent moisture build up. As a Uncategorized remedy of hemorrhoids you can use Venapro. It works fast on the symptoms of hemorrhoids and cures it safely. Hemorrhoids home treatment is the best solution to prevent from the dangerous condition of hemorrhoids. So use this home treatment and reduce the symptoms of hemorrhoids.

Planning and Design of Behavioral Healthcare Facilities

Behavioral Healthcare Facilities: The Current State of Design

In keeping with most districts of healthcare, the marketplace has seen a boom in the construction of Behavioral Healthcare facilities. Contributing to this increase is the paradigm shift in the way society views mental illness. Society is placing a heavier value on the need to treat people with serious addictions such as alcohol, prescription and elicit drugs. A large percentage of people suffering from behavioral disorders are afflicted with both mental and addictive behaviors, and most will re-enter communities and either become contributors or violators.

These very specialized facilities do not typically yield the attention from today’s top healthcare designers and their quantity accounts for a small fraction of healthcare construction. However, Behavioral Healthcare projects are increasing in number and are being designed by some very prominent architectural firms such as Cannon Design and Architecture Plus. Many are creating state-of-the-art, award-winning contemporary facilities that defy what most of us believe Behavioral Healthcare design to be.

Changing the Way We Design Behavioral Healthcare Facilities

As with all good planners and designers, A+D (along with facility experts) are reviewing the direct needs of patient and staff while reflecting on how new medicine and modern design can foster patient healing rates, reduce environmental stress, and increase safety. This is changing the face of treatment and outcome by giving the practitioner more time to treat because they require less time and resources to “manage” disruptive patient populations.

The face of Behavioral Healthcare is quickly changing. No longer are these facilities designed to warehouse patients indefinitely. And society’s expectations have changed. Patients are often treated with the belief that they can return to their community and be a contributor to society. According to the National Association of Psychiatric Health Systems (NAPHS), depending on the severity of illness, the average length of stay in a Behavioral Healthcare facility is only 9.6 days.

What has changed?

Jaques Laurence Black, AIA, president and principal of New York City-based daSILVA Architects, states that there are two primary reasons for the shortened admission period:

1. Introduction of modern psychotropic drugs that greatly speed recovery

2. Pressures from insurance companies to get patients out of expensive modes of care

To meet these challenges, healthcare professionals are finding it very difficult to effectively treat patients within the walls of antiquated, rapidly deteriorating mental facilities. A great percentage of these facilities were built between 1908 and 1928 and were designed for psychiatric needs that were principled in the belief to “store” not to “rehabilitate.”

Also impacting the need for Behavioral Healthcare construction is the reluctance of acute-care facilities to provide mental health level services for psychiatric or addiction patients. They recognize that patient groups suffering from behavioral disorders have unique health needs, all of which need to be handled and treated only by very experienced healthcare professionals. This patient population also requires a heightened level of security. Self-harm and injuring staff and other patients are major concerns.

The Report of the Surgeon General: “Epidemiology of Mental Illness” also reports that within a given year about 20% of Americans suffer from a diagnosable mental disorder and 5.4% suffer from a serious mental illness (SMI ) – defined as bipolar, panic, obsessive-compulsive, personality, and depression disorders and schizophrenia. It is also believed 6% of Americans suffer from addiction disorders, a statistic that is separate from individuals who suffer from both mental and addiction disorders. Within a given year it is believed that over one-quarter of America’s population warrants levels of mental clinical care. Even if these statistics were cut in half, it cannot be denied as a serious societal issue.

With a growing population, effectively designing in accordance with such measures is at the heart of public health.

Understanding the Complexity of Behavioral Healthcare Design

Therefore, like Corrections, leading planners and designers specializing in Behavioral Healthcare are delving deeper to better understand the complexity of issues and to be the activist to design facilities that promote treatment and healing – and a safer community.

The following is a list of key design variables that are being studied and implemented:

1. Right Sizing

2. Humanizing Materials and Color

3. Staff-Focused Amneties and Happiness

4. Security and Safety

5. Therapeutic Design Tenants

Right-sizing

Today’s Behavioral Healthcare facilities are often one-story single buildings within a campus size. Often debated by Clients due to costs, this design preference is driven by the demand for Uncategorized light, window views to nature for all patient areas, and outdoor open-air gardens “wrapped” within. All of this provides soothing qualities to the patient, reduces their anxieties, counteracts disruptive conduct and helps to reduce staff stress.

“When you look at the program mix in these buildings, there’s a high demand for perimeter because there are a lot of rooms that need Uncategorized light. Offices, classrooms, dining areas, community rooms, and patient rooms all demand Uncategorized light, so you end up with a tremendous amount of exterior wall, and it forces the building to have a very large footprint.” – James Kent Muirhead, AIA, associate principal at Cannon Design in Baltimore

These design principles are also believed to improve staff work conditions. Unlike a multi-story complex, at any moment staff can walk outdoors and access nature, free from visual barriers, and within a building that more accurately reflects building types that both patients and staff would encounter in their communities.

In addition to right-sizing for the overall building footprint, is right-sizing for internal patient and staff support area. Similar to the move we have seen in Corrections to de-centralize support spaces, Behavioral Healthcare is moving to decentralized nursing/patient units called “neighborhoods.” With mental health facilities there is a large concern with distances and space adjacencies in relation to the patient room and patient support areas such as treatment and social spaces. Frank Pitts, AIA, FACHA, OAA president of Architecture Plus, Troy, NY, advocates neighborhoods that average 24-30 beds arranged in sub-clusters, called “houses”, of 8-10 beds. Thus, each neighborhood consists of three houses. Often these layouts will include a common area where patients congregate and socialize, with a separate quiet room so patients can elect to avoid active, crowded areas. In addition Pitts states, “There’s a move away from central dining facilities. So, while facilities will still have a central kitchen, it’s a whole lot easier moving food than it is patients.” However, it is important for the facility to mimic normal outside daily life routines, so patients are encouraged to frequently leave their neighborhoods to attend treatment sessions, and outdoor courtyards.

Humanizing Materials & Color

In all facilities that play a role in rehabilitation, design strives to create spaces that humanize, calm, and relax. Behavioral Healthcare patients need to feel that they are in familiar surroundings; therefore, the architectural vocabulary should feel comfortable and normal. Since these facilities are about rehabilitation (when possible) and encouraging patients to merge back into society, the facility should feel like an extension of the community. Their spaces should reflect the nature and architecture of the surrounding region and thus so, no two facilities should look too much alike.

“Our a
pproach to designing these facilities is to view the facility as an extension of the community where patients will end up when they’re released. Interior finishes also depend on geography because you want to replicate the environment patients are used to. You want to de-stigmatize the facility as much as possible.” – Tim Rommel, AIA, ACHA, OAA, principal with Cannon Design in Buffalo, NY.

Therefore, materials and colors within these spaces want to feel familiar to one’s region and everyday life. To soothe the psyche and rehabilitate, they want to feel soft and comfortable, yet visually stimulating. An interior that is overly neutral or hard in appearance is not appropriate. Materials should reduce noise, and colors should lift the spirit. This can help to create an environment in which the patient can learn, socialize, and be productive while easing anxieties, delivering dignity, and modifying behavior. As stated previously, behavioral studies advise the use of softer interior materials-like carpeting, wood doors and tile. Doing so translates directly to both patient and staff well-being, particularly staff safety, and makes for a nicer place to work. In addition, staff have more resources to “treat” instead of manage heated situations. When staff experiences are eased and satisfied, morale is boosted and life-saving rules and policies are more likely to be enforced.

Staff-Focused Amenities & Happiness

While reducing staff stress and fatigue through a healing supportive environment seems like an obvious goal, there are relatively few studies that have dealt with this issue in any detail. More attention has been given to patient outcomes. However, many leading hospitals that have adopted therapeutic tenants into their newly built environments have seen vast improvement through their “business matrixes” and financial reporting.

In one example, the Mayo Clinic, a national leader in implementing healing design in its facilities, has reported a reduction of nursing turnover from a national annual average of 20% to an annual 3%-4%. In another example, when Bronson Methodist Hospital incorporated evidence-based design into its new 343-bed hospital, they cited their 19%-20% nurse turnover rate dramatically dropped to 5%.

Now, both the Mayo Clinic and Bronson Methodist Hospital have had to initiate a waiting list for nursing staff seeking positions. This converts to better-trained and qualified staff, and a reduced error rate. Therefore, more health facilities are investing in staff support areas such as lounges, changing rooms, and temporary sleep rooms. Within these staff spaces and in the hospital throughout, facilities are also recognizing the need for upgrade materials, better day lighting, and an interesting use of color: One soon realizes that the need of patients and staff are interwoven, each impacting positively or negatively the other.

Security & Safety

Without debate, self harm and harm to staff is one of the biggest concerns mental health facilities manage. Often the biggest safety and security concern is the damage patients can do to themselves. “There are three rules I had drummed in me,” says Mark Hanchar; Director of Preconstruction Services for Gilbane Building Company, Providence, R.I. “First, there can’t be any way for people to hang themselves. Second, there can be no way for them to create weapons. Third, you must eliminate things that can be thrown.” Hanchar says that the typical facility is, “a hospital with medium-security prison construction.” This means shatter proof glass, solid surface countertops (laminate can be peeled apart), stainless steel toilets and sinks (porcelain can shatter), push pull door latches and furniture that cannot be pulled apart and used as a weapon. These are just to name a few.

Additionally, removing barriers between patients and nursing staff is a safety consideration. Frank Pitts, AIA, FACHA, OAA president of Architecture Plus, says what may be counter-intuitive for safety precautions, “Glass walls around nursing stations just aggravate the patients.” Removing glass or lowering it at nursing stations so patients can feel a more human connection to nurses often calms patients. There is also discussion of removing nursing stations altogether; decentralizing and placing these care needs directly into the clinical neighborhoods and community spaces. Pitt says, “The view is that [nursing staff] need to be out there treating their patients.”

Therapeutic Design Tenants

As medicine is increasingly moving towards “evidence-based” medicine, where clinical choices are informed by research, healthcare design is increasingly guided by research linking the physical environment directly to patient and staff outcomes. Research teams from Texas A&M and Georgia Tech sifted through thousands of scientific articles and identified more than 600 – most from top peer-reviewed journals – to quantify how hospital design can play a direct role in clinical outcomes.

The research teams uncovered a large body of evidence that demonstrates design features such as increased day-lighting, access to nature, reduced noise and increased patient control helped reduce stress, improve sleep, and increase staff effectiveness – all of which promote healing rates and save facilities cost. Therefore, improving physical settings can be a critical tool in making hospitals more safe, more healing, and better places to work.

Today’s therapeutic spaces have been defined to excel in 3 categories:

1. Provide clinical excellence in the treatment of the body

2. Meet the psycho-social needs of patients, families, and staff

3. Produce measurable positive patient outcomes and staff effectiveness

Considering the cost of treating mental illness, which is exceedingly high, and wanting facilities to have effective outcomes, a further practice of incorporating therapeutic design is increasing. The National Institute of Mental Health (NIM H) approximated in 2008 that serious mental illnesses (SMI ), costs the nation $193 billion annually in lost wages. The indirect costs are impossible to estimate.

The estimated direct cost to clinically treat is approximately $70 billion annually and another $12 billion spent towards substance abuse disorders. In addition to the increased need of care and the boom in Behavioral Healthcare construction, it becomes an obligation to make certain that we as facility managers, architects, designers and manufacturers therapeutically plan and design these facilities.

Notably, in 2004, “The Role of the Physical Environment in the Hospital for the 21st Century: A Once-in-a-Lifetime Opportunity,” published by Roger Ulrich P.H.D., of Texas A&M University, was released. In a culmination of evidence-based research, research teams found five design principles that contributed significantly to achieving therapeutic design goals.

The report indicates five key factors that are essential for the psychological well-being of patients, families and staff, including:

1. Access to Nature

2. Provide Positive Distractions

3. Provide Social Support Spaces

4. Give a Sense of Control

5. Reduce or eliminate environmental stress

Access to Nature

Studies indicate that nature might have the most powerful impact to help patient outcomes and staff effectiveness. Nature can be literal or figurative – Uncategorized light, water walls, views to nature, large prints of botanicals and geography, materials that indicate nature and most importantly, stimulating color that evokes nature. Several studies strongly support that access to nature such as day-lighting and appropriate colorations can improve health outcomes such as depression, agitation, sleep, circadian rest-activity rhythms, as well as length of stay in demented patients and persons with seasonal affective disorders (SAD).

These and related studies continue to affirm the powerful impact of Uncategorized elements on patient recovery and stress reduction. Thus, it is clea
r that interior designs which integrate Uncategorized elements can create a more relaxing, therapeutic environment that benefits both patients and staff.

Positive Distractions

These are a small set of environmental features that provide the patient and family a positive diversion from “the difficult” and, in doing so, also negate an institutional feel. These can be views to nature, water walls, artwork, super imposed graphics, sculpture, music – and ideally all of these want to be focused on nature and, when applicable, an interesting use of color. Therapeutic environments that provide such patient-centered features can empower patients and families, but also increase their confidence in the facility and staff. This helps with open lines of communication between patient and caregiver.

Social Support Spaces

These are spaces designed partially for the patient but mainly for the comfort and socialization of family members and friends of the patient; therefore, family lounges, resource libraries, chapels, sleep rooms and consult rooms all play a role. When family and friends play a key role in a patient’s healing, these spaces encourage families to play an active role in the rehabilitation process.

Sense of Control

In times when patients and family feel out of control, it is very healing for the facility design and staff to provide it back when appropriate. Although, this cannot always be done suitably in mental healthcare facilities. However, when applicable, these design features include optional lighting choices, architectural way-finding, resource libraries, enhanced food menus, private patient rooms and

optional areas to reside in. A few well-appointed studies in psychiatric wards and nursing homes have found that optional choices of moveable seating in dining areas enhanced social interaction and improved eating disorders. When patients feel partially in control of their healing program and that the building features are focused to them, an increased confidence of the quality of care enters and tensions lower.

As with all therapeutic design, this allows the caregiver to use their resources healing in lieu of “managing” patient populations.

Reduce or Eliminate Environmental Stress

Noise level measurements show that hospital wards can be excessively noisy places resulting in negative effects on patient outcomes. The continuous background noise produced by medical equipment and staff voices often exceeds the level of a busy restaurant. Peak noise periods (shift changes, equipment alarms, paging systems, telephones, bedrails, trolleys, and certain medical equipment like portable xray machines are comparable to walking next to a busy highway when a motorcycle or large truck passes.

Several studies have focused on infants in NIC Us, finding that higher noise levels, for example, decrease oxygen saturation (increasing need for oxygen support therapy), elevate blood pressure, increase heart and respiration rate, and worsen sleep. Research on adults and children show that noise is a major cause of awakening and sleep loss.

In addition to worsening sleep, there is strong evidence that noise increases stress in adult patients, for example, heightening blood pressure and heart rate. Environmental surfaces in hospitals are usually hard and sound-reflecting, not sound-absorbing causing noise to travel down corridors and into patient rooms. Sounds tend to echo, overlap and linger longer.

Interventions that reduce noise have been found to improve sleep and reduce patient stress. Of these, the environmental or design interventions such as changing to sound-absorbing ceiling tiles, are more successful than organizational interventions like establishing “quiet hours.”

Conclusion and Additional Information

The information contained in this excerpted report is intended as a guide for architects, specifiers, designers, facility planners, medical directors, procurers, psychologists and social workers which have a stake in providing improved facilities for behavioral healthcare patients. It is a portion of a report entitled “The Contributions of Color” authored by Tara Hill, of Little Fish Think Tank. Ms. Hill was commissioned by Norix Group Inc., in 2010 to research the role color plays in the safe operation of correctional facilities and behavioral health centers. More in-depth information specifically about the psychological influence of color and behavioral healthcare facility design can be found by reading the full report.