PART 3: BRINGING SPACES BACK TO LIFE Considerations for HEALTHCARE Adaptive Reuse Projects

Healthcare Construction Insights

Finding a competitive advantage amid decreasing reimbursements and increasing costs is a seemingly perpetual conundrum for health systems. Transferring services to less costly off-campus settings can provide an answer to slimming profit margins, but is consuming precious financial resources through a new build always the right strategy?

As the demand for commercial office and retail real estate ebbs, breathing new life into otherwise unproductive properties is one way to increase overall market footprint, boost community vitality, serve patients more effectively, and provide solid returns.

In Part 3 of this five-part series, we're getting down to the nuts and bolts of adaptive reuse construction. From building envelope assessment to zoning of mechanical systems, we’ll dig into a few of the details to help you decide if a property measures up.

Funded by profits generated from Movement Mortgage, the Movement Foundation converts an existing one-story, multi-tenant building basement to a state-of-the-art medical clinic for Novant Health. The clinic includes 12 exam rooms, 2 full nurse stations, and child-friendly waiting areas.

Adaptive Reuse Defined

As systems expand and shift, retrofitting space is an increasingly popular strategy. But first, what is adaptive reuse, and how does it differ from a building renovation?

Although there is a significant renovation component to every adaptive reuse project, it is much broader in its definition. Simply: Adaptive reuse is a strategy which existing buildings are updated for a new purpose.

For example, it’s transforming a former sporting good store into a non-profit healthcare center or converting an abandoned mattress factory into lab space to support medical and bioscience research.

Diamonds in the Rough or Bona Fide Money Pits?

Abandoned and underutilized structures – whether retail, office, or industrial – offer many advantages for the healthcare sector, from open floor plates to abundant parking and often premium location visibility. Moreover, the inventory of available buildings continues to grow as brick-and-mortar retail moves online and the COVID-19 pandemic pushes telecommuting to new levels.

In many cases, the repurposed space can be made operational more quickly than new construction, at a lower cost, and in a more environmentally-friendly manner.

But before moving forward with an adaptive reuse project, it’s important to understand the opportunities and obstacles that can affect project cost, schedule, feasibility, and ROI.


With over 32.3 billion square feet of existing core commercial real estate space on the market, the opportunities are nearly limitless for health systems and health care providers, but the property has to be the right fit – legally permissible, physically supported, economically feasible, and maximally productive.

When brought in early, your contractor can be a valued partner in the repurposing process, working with the design team and key stakeholders to effectively and successfully tackle the challenges associated with your adaptive reuse project, including:

Code Implications | Site Conditions | Building Envelope | Environmental HazardsStructural Support Systems | MEPF and Low Voltage Systems | Concrete Slab & Flooring | Vertical Circulation

Understand Code Implications

Code-minimum design and construction for corporate and retail structures is commonplace with much less stringent requirements than healthcare by comparison.

Early engagement of the Authorities Having Jurisdiction (AHJ) and the project team provides opportunities to determine where code deficiencies exist, where more invasive work might be required, and how the intent of the code can be met with minimal changes.

Furthermore, with the integration of Virtual Design & Construction technology, project teams can provide AHJs with designs that realistically consider variables such as constructibility, manufacturer specifications, subcontractor practices, and system performance details. This avoids the seemingly endless cycle of redocumentation and reinspection previously typical.

For more information on this topic, explore Part 2 of this healthcare construction series, "Navigating the Regulatory Roadmap."

Get Off on the Right Foot

Exterior Aesthetics. The simple act of visiting a physician’s office or surgery center can be stressful for patients. An office or retail site might boast easy access and ample parking, but does the exterior reflect a healing and caring environment? Reducing anxiety before patients step in the door is critical.

A cost analysis exercise can help determine whether facade updates (i.e., interjecting glass or steel elements) can achieve the desired impression or whether a full re-skin is required.

In cases where preserving the historic nature of a property is desired or required, a contractor's ability to source products and services considered obsolete cannot be understated. Extensive trade connections, creative solutions, and innovative approaches will be necessary for effective budgeting, buyout, and for overall quality purposes.

Parking and Circulation. The needs of able-bodied shoppers and office workers differ greatly from those seeking medical attention. Both the quantity of parking and the proximity of those spaces to covered drop-off zones should be considered. For sites with existing parking decks, vehicle flow, drainage, durability, accessibility (stairs and elevators), and code compliance should be assessed to accommodate the change in use.

In addition to the above, existing sidewalks and paved parking surfaces should be smooth, easily navigable, and in compliance with ADA requirements. Asphalt overlays, full-depth patching, and crack treatments are among the less costly alternatives to full lot milling and filling.

Inspect the Building Envelope

Water Intrusion Assessment. Is the existing structure watertight, well-insulated, and free of mold and mildew?

A building envelope assessment of the roof, windows, doors, and the above- and below-grade wall systems reveal impacted areas and provide recommendations for an appropriate repair or restoration program. IR thermography, for instance, can be used by Choate's team to identify a wide range of issues including air leakage, inadequate or incorrectly applied insulation, moisture infiltration and/or poor moisture barriers, and other potential maintenance issues.

Did you know? The number one cause of loss in the construction industry is due to water infiltration. It is for this reason Choate made the proactive investment of an in-house Building Envelope Specialist with over 35 years of experience in focusing on the minute details that can contribute to water infiltration. Our specialist also brings a practical depth of experience to complement any third-party consultants that may be engaged.

Thermal Resistance. Do the existing exterior walls and roofing insulation meet today’s energy code requirements?

Choate is dedicated to reducing life cycle and consumption costs and improving building performance. Improving the R-value (a material’s ability to resist thermal movement throughout) provides for reduced energy consumption and reduced long-term operating costs. New roofing systems also provide the advantage of being fully warrantied, and when installed properly, leak-free for years.

Don't miss part 5 of our series, "Better Building for Better Healing," where we'll discuss building performance, sustainability measures, and infection control in healthcare construction. Coming soon!

Assess & Abate Environmental Hazards

Environmental contaminates (e.g., asbestos, lead-containing materials, bat and bird droppings, PCBs, etc.) can be significant cost drivers if not identified early.

Once an assessment occurs and contaminants identified, Choate can, if desired, develop a remediation plan for disturbance and disposal of hazards. This will provide the owner with a path for successfully navigating potential impacts. It accounts for local, state, and federal regulations; accommodates for the safety of the individuals performing the work; and addresses associated cost impacts and required schedule modifications.

Ensure a Sound Structural Support System

A change in building use requires an accurate assessment of the building structure. When considering extensive storefront glass systems, penthouse additions, or vertical expansions, the structural load capacity limits should be assessed. Structural steel and foundation modifications can sometimes be required to support added loads for installation of imaging equipment and associated shielding, when hanging mechanical piping, or when placing rooftop HVAC equipment.

3-D Laser Scanning. When modular partitions are dependent on floor flatness or building around existing MEP systems requires exact precision, an understanding of your existing as-built conditions is critical. 3D laser scanners allow precise capture of these conditions, enabling understanding of the new design within its existing context or to verify installed components.

Floor-to-Floor Height Constraints. Reworking the building structure is common practice to address situations where floor-to-floor heights are limited (office) or expansive (big box retail). Internal and external sound transmission, patient privacy regulations, fire ratings requirements, and interstitial space constraints for medical-specific systems (medical gases, isolated exhaust ducts, additional plumbing, etc.) most commonly need to be addressed.

For expansive floor-to-floor heights, the construction and installation of a separate structural grid attached to the main roof can allow for support of utilities, piping, and ductwork. It can also serve as an anchor point for many of the internal walls, avoiding the cost of running partitions to the deck. Sensitive discussion areas can be further isolated through a variety of sound-masking techniques and materials.

MEPF & Low Voltage Systems

Mechanical Systems. Outside of light medical applications, the mechanical needs of retail and office environments are drastically different than those of healthcare settings in terms of code and performance requirements. Systems serving retail, for example, are designed to serve wide, open areas; temperature control features, filtration, and zoning are often kept minimal.

By contrast, most healthcare spaces require multiple control points and zones (exam and waiting rooms, imaging rooms, etc.). Humidification/dehumidification, filtration, and pressurization requirements, must also be considered. Pre-planned strategies for zoning and tweaking systems can sometimes help avoid full replacement.

The preconstruction planning phase also provides opportunities to identify necessary infection control measures, such as UV filter placement and fresh air requirements. We'll explore these topics further in Parts 4 and 5 of this healthcare construction series.

Electrical Systems. The power consumption demands of retail and office spaces are considerably lower than those within healthcare. Specialized equipment and increased occupancy levels will require a thorough review and updates to existing wiring, distribution, and applicable codes.

If diagnostic and treatment equipment will be required, it is critical to determine whether such systems have higher voltage requirements than available and whether a new electric service install is required.

If mobile diagnostic imaging services are to be provided, the appropriate electrical infrastructure should be added to the budget to support the increased load capacities demanded. Existing emergency power systems should also be evaluated to determine sufficiency for supplying lighting and equipment power.

Plumbing Systems. Healthcare spaces typically contain three to four times more plumbing fixtures than office and retail, with various output temperatures often required by code for specific fixtures.

Slab-on-grade construction, typical for retail structures, can present challenges when installing new piping to support new water and sanitary services. Depending upon the condition of the existing concrete slab and vapor barrier, the amount of cutting and patching required, and the desired new floor finishes, your contractor can advise whether it's more economical to remove and replace most/all of the slab in lieu of cutting and patching.

Likewise, early partnering with the contractor can help ensure infection mitigation measures are assessed, planned, and implemented within the construction phase. Inspections for dead legs and back-siphonage in piping, for example, are two ways to ensure domestic water systems run clean.

Fire Protection. A proactive, cost-effective, and practical approach to fire protection in an adaptive reuse scenario should include, for example, early assessment of existing risers and flow rates, wall and deck fire ratings (existing and required), and emergency access and egress points.

Proactive, early communication with the AHJ by the project team is key to ensuring the intent of the codes can be met with invasive work minimized, risks mitigated, and results maximized.

Did you know? Long after the paint has dried and the keys turned over, knowing what’s behind those walls may become important. Rather than playing Operation on your drywall, using automated jobsite capture software during construction leaves teams with x-ray functionality, thus components like backing, MEPs, rebar and cabling are located. This knowledge reduces risk and improves accuracy for future projects.

Low Voltage Systems.The importance of properly installed low voltage systems, those powered by fiber optic and copper cabling, cannot be understated; the technology infrastructure needs of the healthcare sector grow more integrated and complex by the day. From door access control systems, video surveillance, and call systems to electronic health records and wireless technology distribution --- LVS serve as a facility's backbone, keeping operations running fluidly in the digital era.

The likelihood existing infrastructure will suffice is slim; proper planning of such systems is paramount. Information communication technology systems should be carefully integrated from initial design through construction, commissioning and turnover to control project costs and alleviate scheduling challenges.

Scheduling low-voltage infrastructure and associated network buildouts toward project completion, a traditional approach, risks creating technology silos that reduce or prevent network convergence. This practice can also complicate future network upgrades and consistency in connectivity essential to long-term access and productivity.

Cracks and Moisture in the Concrete? Assess the Slab

Healthcare environments maintain stringent tolerances for floor flatness and levelness, due in part to ADA and equipment requirements. A proper assessment of the slab will note areas where cracking, settling, heaving, and moisture occur. Each can be indicators of a poor quality slab, improper subgrade leveling, and/or ground moisture problems. Areas where grinding and leveling may be required after existing flooring is removed should be identified.

Address Vertical Circulation

Multi-floor buildings may require upgrades to support expanded patient volume. Additional stairwells may be required. Elevators should be conveniently located for patient use and the size of the cab should be ample to support necessary medical equipment.

Finding a facility with good bones and bringing it back to life is achievable, highly rewarding, and provides a quick avenue to get system services to market faster. With the right partners, approach, and proper due diligence, adaptive reuse construction can re-open the doors to otherwise underutilized properties at a lower cost than a new build.

Now that you have the basics of our approach to adaptive reuse in healthcare construction, get in touch with one of our experts to learn more. Email us directly or visit our portfolio pages to see more healthcare project experience.

Don't miss Part 4 of this series, "Bringing Spaces Back to Life: Considerations for Inpatient Renovations," coming soon!

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Choate Construction