Sheltering Arms Institute’s gym features plenty of natural light, as well as space to recover and practice new skills.

Building A Better Rehab Hospital


Spaulding Rehabilitation Hospital exterior

As soon as David Estrada rolled into the construction zone that was set to become the new gym at the heart of a $225 million renovation of Spaulding Rehabilitation Hospital Boston, he could see something was wrong. Actually, it’s what he couldn’t see that was wrong.

The panoramic windows intended to provide a striking view of the Mystic River were too high off the ground for wheelchair users to see out. “I said, ‘You guys must really want people to walk again because I can’t see the view,’” says Estrada, a T3 paraplegic.

David Estrada
David Estrada

It’s the kind of oversight that contractors might not have noticed and never would have changed. Thankfully, Spaulding took the time to get feedback from Estrada and a group of stakeholders with SCIs.

Oswald Mondejar, senior vice president for the care network that manages Spaulding, remembers being stunned by Estrada’s observation. “I knew right away that we had to fix this,” he says. As a person with a disability of his own, it was personal. “I raised [the argument for lower windows]. It was a significant retrofit with a lot of dollars behind it, but our president ultimately stuck by us. That took a little bit of … not coercing, but really explaining why it was important for us to not only provide access, but symbolically make this shift.”

Using his background in hospitality, Mondejar framed the discussion as a customer-first mentality where simply complying with the minimum requirements of the ADA wasn’t good enough. “Our tagline here is, ‘beyond compliance,’ so how we approached this whole project was very targeted,” he says. “We offer patient-centered care, and we want to reflect those who come through our doors in everything we do.”

“Patient-centered care” means that Spaulding treats the people it serves according to what they want and feel is important. To do this well, the rehab needed facilities that worked for them — and to make that happen, it needed input from stakeholders like Estrada.

The remodeled hospital opened in April 2013 — with the redesigned windows — and stands as a prime example of a growing trend of rehabilitation facilities going beyond ADA requirements and incorporating input from the disability community to build more accessible and inclusive buildings.

Boston’s Spaulding Rehab is now bright and cheery, and goes far beyond ADA requirements. The gym features floor to ceiling windows.
Boston’s Spaulding Rehab is now bright and cheery, and goes far beyond ADA requirements.

What to Do With Aging Facilities

Twenty-five years ago, when Estrada was undergoing rehab at the old Spaulding Rehabilitation Hospital after a motorcycle accident, he remembers overhearing people as they toured the hospital.

“There were seven different hospitals to choose from back then. When people would enter the old Spaulding building, they’d say, ‘This place looks gross. It looks like it’s the 1970s,’ and they would go to some other place. Even though they would receive great care and treatment, people would literally not go to Spaulding because of its appearance,” says Estrada.

Built in the 1970s, the building featured little natural light, making it difficult to navigate. Many of the existing accessibility features were retrofitted, rather than being seamlessly integrated into the design from the beginning.

Modern Main Therapy Gym at Sheltering Arms features plenty of natural light, as well as space to recover and practice new skills.
Sheltering Arms Institute’s gym features plenty of natural light, as well as space to recover and practice new skills.

As one of 14 SCI Model Systems Centers recognized for providing the highest level of care, Spaulding felt a responsibility to represent the accessible ideal for its patients, staff and students in its remodeling plans. Not only that, but it knew becoming radically inclusive would give it a competitive edge over other rehab destinations.

A few years after those discussions, a team of planners in Richmond, Virginia, faced similar dilemmas as they looked to bring three smaller hospitals — Sheltering Arms Hanover, Sheltering Arms South and Virginia Commonwealth University Health — under one roof as a state-of-the-art inpatient rehab facility.

In place of dated facilities where accessibility had been retrofitted as an afterthought, they envisioned a one-stop shop that combined the experience and research power of VCU Health with the technological innovations of Sheltering Arms. They dubbed their vision Sheltering Arms Institute. Like the team behind Spaulding’s remodel, they wanted to foster collaboration between clinicians, therapists, patients, vendors and community partners like United Spinal, so that everything was run from a central hub.

Both Sheltering Arms and Spaulding identified the importance of innovative thinking and centering their plans around patients’ needs. One example of innovative thinking came when Spaulding’s CEO asked the project’s designers to navigate the old Spaulding building using wheelchairs.

Spaulding’s warm aquatherapy pool relaxes muscles, increases blood flow and makes movement easier.
Spaulding’s warm aquatherapy pool relaxes muscles, increases blood flow and makes movement easier.

“That was an aha moment for us,” says Jessica Stebbins, former senior principal and associate project manager for Perkins + Will, the architecture and design team on the Spaulding project. “Not having the independence or control over where we wanted to go was revealing.

We tried to get into the patient room bathroom, but the door was too narrow so we couldn’t get in.”

Spaulding also gave Stebbins’ team wheelchairs and walkers to take back to the office to help them with mock-ups, such as testing knee clearances for sinks or designing more ergonomic faucets that wouldn’t put stress on users’ shoulders. Stebbins would go on to share many of these insights with the team planning Sheltering Arms Institute as a consultant, but she says the most valuable insights came from listening to the experiences of those who live with spinal cord injuries.

“Involving those with SCIs of various levels was important to the design team because we wanted to design a facility that was truly inclusive from an experiential standpoint and broke down physical barriers, so everyone has more parity in experience and access,” she says.

The medical and hospital experts at Spaulding knew that the real expertise needed had to come from community members. “We went beyond the voice of the patient at Spaulding Rehab because we wanted to engage advocates. Folks that are challenging the status quo. Folks that know what the challenges are, that have been doing the work for many years or have been compelled to advocate for themselves in the community,” says Mondejar. “We didn’t shy away from being challenged. We wanted those voices.”

The exterior of Sheltering Arms Institute
The exterior of Sheltering Arms Institute

A Bar in a Hospital?

In addition to town halls and traditional outreach, Spaulding asked leaders of Massachusetts’ SCI community like Estrada, the late Travis Roy and the late Betsy Pillsbury what the disability community would like to see in an ideal rehab center. Similarly, the Virginia team reached out to local YouTuber Cole Sydnor and Richard Bagby, director of the Virginia Chapter of United Spinal Association, who rehabbed at VCU.

“We threw everything out there. Nothing was too extreme,” remembers Bagby, who attended one of the three initial workshops that were attended by about 150 people each. “In those initial meetings, people were talking about different pieces of technology. A big idea was single-patient rooms, and I think a couple folks asked for a rooftop bar.”

A bar in a hospital may sound odd, but Sandra Tkcaz, vice president and healthcare principal at HDR, who helmed the design of Sheltering Arms Institute, says her team was guided by the underlying idea that people in rehab and their families needed space to relax that didn’t necessarily look like a hospital.

“One really important thing we learned from those early design sessions was that people with new complex spinal cord injuries may not be ready to enjoy the rest of the institute until the latter part of their stay. Their unit needed to be bright, supportive and welcoming, while having a satellite dedicated gym, as well as lift technology in every room,” she says. “Also, they need all the rooms and support spaces, like the family lounge, to have a lot of room to maneuver and enjoy,”

Once those initial meetings ended, Bagby and Sydnor continued to make their voices heard as part of a 20-member design steering committee. They helped push the committee to go beyond ADA requirements in several instances, including installing low-effort, sliding barn doors for bathrooms. They also found compromises that wouldn’t overly dilute access for wheelchair users.

“There was a discussion about installing flooring that was softer for the nurses and folks who were on their feet all day long. But, as wheelchair users, we prefer something that’s harder and creates less friction,” says Bagby. “So we took those ideas from both groups and married them together.”

Alan Lombardo, a physical therapist on an SCI unit for six years before becoming CEO of the Sheltering Arms Institute, highlighted the value that Bagby and Sydnor brought to the design. “The world is uniquely different for people with SCIs — or anyone with mobility impairments — so even though I’ve worked directly with members of those populations, I can’t possibly see the world the way they see it,” he says. “It was critically important to have folks with lived experience in the early stages of planning to ensure the facility was accessible for the SCI community.

Bagby was equally pleased with the process. “It was refreshing to have people come to me and ask what would be ideal. I didn’t have to frame the discussion around it,” he says. “Instead, it was, ‘Hey, would this work for you? How could it be better?’ They were so aware that they don’t experience what a wheelchair user experiences that I’d be honest and say, ‘it could be better this way’ or ‘it’s fine.’”

A peek into a therapy session, where a woman is able to simulate walking down a street on a treadmill..
A peek into a therapy session, where a woman is able to simulate walking down a street.

A Depth We Would Have Missed

When Spaulding opened its new 262,000-square-foot, 132-bed, $225 million facility in 2013, it immediately became the standard-bearer for rehab hospitals that it sought to be. Natural light permeates the building, the hallways have ample width, the sinks in the public washrooms have a higher clearance underneath than what is required by the ADA and all the stalls are big enough for a wheelchair user to turn around in. The patient rooms are designed to be navigated by wheelchair, with custom cabinetry at seated level. Also, they feature automated shades, lifts, private bathrooms and amenities such as private refrigerators, Wi-Fi and sleeping accommodations for family members.

Wearing hardhats and yellow vests in a construction zone, wheelchair users were involved at every stage of planning for Sheltering Arms.
Wheelchair users were involved at every stage of planning for Sheltering Arms.

Other highlights include a street-level entrance, a lower and rounded reception desk, a pool for aquatherapy, two state-of-the-art gyms and an activities-of-daily-living suite. There are also transitional apartments and satellite gyms embedded on two inpatient floors. The environment lends itself to making it easier for wheelchair users to be directly involved in their care.

“If you’re in a regular hospital, there are places where clinicians can write their narrative on each patient. Typically, they’re not accessible, but for our floors, they’re all accessible,” says Mondejar. “You can bring the screen and keyboard down just with a slight movement.”

All of the effort to collaborate with the community paid off with a forward-thinking facility that continues to deliver dividends to this day. “The involvement of people with SCIs gave a depth to our work that we would’ve missed otherwise,” says Mondejar.

Seven years after Spaulding’s opening, and about 550 miles southwest on I-95, Sheltering Arms Institute followed suit in June 2020, opening its doors and transforming the Virginia region’s rehab options. Built on 212,000 square feet, the hospital offers 114 beds, a 9,500 square foot therapy gym, three satellite gyms, and contemporary research and care facilities with wheelchair-friendly touches all around.

Take the ceiling tracks that run throughout the building. Seventy percent of patient rooms come equipped with a lift system that can get a person out of bed and transport them right into the washroom. Still, Lombardo is quick to point out, this is just the beginning for Sheltering Arms Institute.

“We’re situated on a 46-acre campus, and we’ve only used about 12 acres of that,” he says. “Right now, we only provide inpatient rehab services. We’re thinking about the future where we would provide outpatient services that are on par with some of the inpatient services we provide, so that when people come here, they feel a sense of community and belonging.”

Lombardo hopes to nourish that sense of belonging by giving space in the planned outpatient building to community partners like United Spinal’s Virginia Chapter and Sportable, Richmond’s local wheelchair sports nonprofit. Spaulding took a similar approach, providing an in-facility office for United Spinal’s Boston Chapter.

A rehab with space for the local SCI community is exactly the point, says Bagby. “The goal wasn’t to build this state-of-the-science building and rest on our laurels,” he says. “The goal, which has not been realized yet, is to develop and build a campus and community. At some point there should be an outpatient gym where people who have been through SCI come back to the same campus to do their outpatient therapy, and so you have people who are fresh into their injuries seeing what is possible down the road.”

Inclusion Pays Dividends

That plan, though in development, is still in the future. In the meantime, both Sheltering Arms and Spaulding recognize the importance of taking what they’ve learned about building accessible, universally designed spaces and evangelizing those lessons to the wider community.

The designers from both Perkins + Will and HDR tell NEW MOBILITY that they’re constantly emphasizing the importance of making spaces accessible. Most clients are receptive and don’t cite cost as a barrier to access, but Stebbins says making things accessible is cheaper than they think. “If you’re starting from scratch, it’s much easier to open things up and think universal design and accessibility than if you were trying to retrofit an existing structure,” she says.

Bagby and Estrada also learned a lot by participating in this collaborative design process. “My takeaways were the inclusivity and the progressive mindset. You need that from leadership,” says Estrada. “The other part is, if you’ve grown up as a nondisabled individual and haven’t had a personal relationship with someone with a disability, your mindset may be, ‘we need to get this done,’ and you’re not thinking about accessibility. You need to put yourself through a multi-factor process as a leader to even start thinking about access. These people made the right decisions and planned accordingly in including us.”

Both he and Bagby realize that despite their experience, the world is still a long way from a reality where these kinds of collaborations are the norm and access is universal. Estrada maintains it starts with the leadership, and Bagby says it ends with the will and motivation.

“I’ll be really hopeful when someone just does universal design without there being anyone with a disability who requests it,” says Bagby, “when it’s something that’s just done automatically.”

See also: Two Craigs on the Cutting Edge


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Sylvia Bennett
Sylvia Bennett
2 years ago

I commend you on your effort. Could you please share how you advance the patient to return to independent living after discharge. Especially things like transferring from bed to chair to toilet and what that would look like in an apartment (what if a person could not use slide board?) Also learning skills like cooking and other needs that would require adaptation related to physical challenges of design

Peg Graham
Peg Graham
2 years ago

Hi Sylvia Bennett – Great question. I have a Small Business Innovation Research grant from the NIH to innovate the bedside commode, making it easier to transfer to/from a wheelchair. Would love to talk with you, and anyone else who is interested in improving the toileting options available to wheelchair users, particularly those who are aging . . .