sustainability

Article
Adaptive Reuse of Social and Healthcare Structures: The Case
Study as a Research Strategy
Marco Gola 1 , Marta Dell’Ovo 2, * , Stefano Scalone 3 and Stefano Capolongo 1

1 Design & Health Lab., Department of Architecture, Built Environment and Construction Engineering (DABC),
via G. Ponzio 31 Politecnico di Milano, 20133 Milan, Italy; [email protected] (M.G.);
[email protected] (S.C.)
2 Department of Architecture and Urban Studies (DAStU), Politecnico di Milano, via E. Bonardi, 3,
20133 Milan, Italy
3 Politecnico di Milano, Piazza Leonardo da Vinci, 32, 20133 Milan, Italy; [email protected]
* Correspondence: [email protected]; Tel.: +39-02-2399-5501

Abstract: The regeneration and reuse of abandoned healthcare facilities represent one of the most
complex issues in the broader field of disused public architectural heritage and its valorization.
The leading causes of an elevated quantity of abandoned hospitals are the lack of resilience of
these structures, as well as the evolution of the regulatory framework used to increase the quality
standards of the National Health System and the constant changes caused by medical discoveries.
In addition, the transfer to a new building typically does not involve consideration of the future of
the dismissed facility with a lack of a strategic view for its regeneration, thus causing its progressive
degradation. Although their large dimensions and unbuilt areas make recovery plans complex, the
re-functionalization of these facilities represents an excellent opportunity for social and economic
development, as several case studies demonstrate. This paper selects some useful examples of the
reconversion and reuse of disused social and healthcare buildings through an accurate comparison





 that highlights the importance of the topic and the possible actions to be taken into consideration.
Citation: Gola, M.; Dell’Ovo, M.; Although this research focuses on a limited number of case studies, the paper gives rise to some
Scalone, S.; Capolongo, S. Adaptive strategies that can be applied to several current cases of disused buildings that could be used to
Reuse of Social and Healthcare support Decision Makers (DMs) from different countries.
Structures: The Case Study as a
Research Strategy. Sustainability 2022, Keywords: regeneration; adaptive reuse; healthcare facilities; hospital reconversion; design strategies
14, 4712. https://doi.org/10.3390/
su14084712

Academic Editor: Asterios Bakolas

1. Introduction
Received: 16 December 2021
Accepted: 10 April 2022
The history of architecture has demonstrated how social, political, and economic
Published: 14 April 2022
transformations strongly affect the design of healthcare settings and the environments
that host public functions and social activities. With the changing demands of society, the
Publisher’s Note: MDPI stays neutral
relationships among various factors highly influence the modalities by which the hospitals
with regard to jurisdictional claims in
and the spaces themselves respond to new needs [1].
published maps and institutional affil-
The evolution of health architecture, along with the transformation and modification of
iations.
types of assistance and therapeutic actions, can be analyzed throughout history; in fact, the
economist Jacques Attalì stated in the book Life and Death of Medicine that there is a concrete
passage from places where we atone for sins, to spaces where we stop “being sick,” to those
Copyright: © 2022 by the authors.
of a dynamic network nature [2]. Hospitalia, the original Latin term for hospital, means
Licensee MDPI, Basel, Switzerland. “guest room”. Parallel to this evolution, hospital structural components, technologies,
This article is an open access article performance, organizational issues, and layouts of functional areas have also all adapted.
distributed under the terms and In the beginning, hospitals were created as environments where hospitalization was at the
conditions of the Creative Commons center of the entire system. Over time, through discoveries in the field of genetic research
Attribution (CC BY) license (https:// and its applications, biotechnologies, and the development of information technologies,
creativecommons.org/licenses/by/ the purposes of these facilities have expanded to include training, research, and other
4.0/). services [3].

Sustainability 2022, 14, 4712. https://doi.org/10.3390/su14084712 https://www.mdpi.com/journal/sustainability

Sustainability 2022, 14, 4712 2 of 18

Beginning from the motto “prevention is better than cure,” current hospital facilities
host not only inpatients, but are also used by healthy individuals, directed to outpatient
and diagnostic services, suitable for prevention and health promotion [4]. Thus, healthcare
architecture, such as other urban services, becomes an active element of cities and public life
for the prevention of disease and the promotion of the health of citizens, as well as creating
a valuable identity for the community [5]. In recent decades, to improve access to services,
promote user satisfaction, and increase the efficiency and effectiveness of health systems,
health infrastructure networks have been established by different countries, creating new
structures of the organizational systems inside cities [6].
Difficulties in providing responses to the recent global pandemic crisis were strongly
influenced by the results of economic cuts in the health sector, with which the National
Health System (NHS) tried to comply by using temporary hospital structures. It remains
difficult to predict future developments and repercussions of this health crisis in social
and economic terms [7,8] although it is now possible and even essential to take advantage
of this renewed attention to the health sector to highlight possible economic and design
strategies useful for supporting the system in the future.
Although newly constructed buildings can better respond to both current and future
demands of healthcare (in terms of flexibility, technology, and structural issues, etc.), it is
fundamental to consider what happens to disused buildings after their lifecycles end [9].
In fact, these facilities, after several decades, obtain a social value with many of them being
safeguarded by competent offices to ensure their physical and historical integrity. It is
evident that such heritage can represent a high-quality resource for both the public and
private sector if properly valued.
The three architectural typologies that historically characterize these buildings are
pavilion, monoblock, and polyblock. These are variably used depending on the type of
pathologies treated and therapy methods, though they all tend to be massive structures
located in the suburbs of cities [10]. Their physical configurations and locations are some
of the critical points of the reconversion process and contemporary adaptation, dictating
compatibility with things such as hospitality or office functions, two common solutions for
recovery processes. Occasionally, the conversion involves the establishment of public and
cultural functions, and rarely, social housing is developed.
In several European countries, legislation regarding building protections is very lim-
ited, while in others—especially for infrastructure of social importance—they are very
strict [11]. As such, these different approaches highly influence the conservation methods
and the lifecycle of structures, providing useful case studies, such as the Martini Hospital
in Groningen, Netherlands, which was built using the principle that it would be totally
disassembled or demolished when its lifecycle ended [12].
Most commonly, as emphasized by the scientific community, re-evaluating an architec-
tural asset through its physical and functional enhancement is to be considered a proper
choice in terms of sustainable recovery [13]. For example, within the Italian context, there
exists a Code of Cultural Heritage and Landscape by which the government promotes the
development of culture, scientific, and technical research; the protection of the landscape;
and historical and artistic heritage [14,15].
To recover an asset in a sustainable way, it is necessary to engage in a spatial, techno-
logical, and economic study so as to not compromise the potential reuse of the facility and
its social identity [16]. For this reason, an in-depth analytical feasibility study is essential to
determining the strengths and weaknesses of the intervention proposal. Presently, recover-
ing an asset means not only restoring its original morphology but also, above all, enhancing
its potential. In addition, because revaluations must follow sustainable environmental and
economic logic, it is necessary to create consistent strategies [17,18].
The strategic actions must consider various fields of interest, including the study
of the conservation status of the facility in order to be able to pre-estimate the costs of
restoration [19]. This type of investigation is essential in the preliminary phase because it
Sustainability 2022, 14, 4712 3 of 18

allows for determining design strategies that can meet the demands and needs detected by
the building itself and related contexts.
The evaluation of possible alternatives of reuse becomes a fundamental issue, as it
allows for planning for which type of re-functionalization is the most suitable. In this
case, it is necessary to know not only the intrinsic features of the property (building type,
surfaces, any green areas available, etc.), but also the socio-economic issues in which the
building is located and its position in the lifecycle [20]. Although it is quite arduous to
explain, the functional program becomes an indispensable tool [21].
This strategy has been implemented in the past. As Pérez de Arce states, the reuse of
buildings for different purposes during the French Revolution, such as military functions,
was a widespread practice [22].
In contrast with the past, currently it is essential to describe the approach in a more
precise and cultured way. In fact, it does not seem possible to determine a common and
unique strategy for the reuse of buildings, because each case has its own intrinsic and
extrinsic peculiarities [23–25]. It is therefore necessary to investigate various issues such as
the degree of adaptability and flexibility of facilities, as well as the ability to merge new
and existing buildings [3]. However, relationships between the past and the present have
often been trivialized by unsuccessful design choices.
In general, the relationship between a building and its surroundings must be the key
element in the proposal’s explanation.
Among the actions that must be taken into consideration is the strategy of adaptive
reuse which is aimed at reusing something that has lost its initial function by adapting
it to a new specific environmental context. According to the Australian Department of
Environment and Heritage, it is a process that changes discarded or inefficient properties
into new ones that can be used for different purposes [26]. Starting from this definition,
the adaptive reuse of a property must be able to foresee future scenarios, based on careful
analyses that have been previously planned and addressed.
In terms of industrial and healthcare heritage buildings, it is essential to consider the
adaptive reuse issue as an occasion of urban regeneration leading to economic and social
growth [27,28]. As several reports on the European Union highlighted, many European
Countries have applied similar strategies, including Portugal, Sweden, Spain, Latvia, Italy,
Greece, Bulgaria, Cyprus, Romania, etc. For example, according to the Italian National
Institute of Statistics (Istat) data, 5.2% of properties in Italy are in a state of disuse, of
which almost 10,000 of them are public and ready for reconversion [14,29]. Among these,
healthcare real estate represents one of the largest shares.

2. Research Strategy
The adaptive reuse of healthcare facilities can be a challenging and complex problem
given the presence of conflictual values (e.g., minimizing initial cost, preserving historical
aspects, compliance with specific contexts, etc.), as well as the involvement of both public
and private stakeholders and the specificity of the building itself, all of which can create
adaptive limits [30,31]. To understand which re-use strategy is most suitable by considering
both the extrinsic and the intrinsic features of the building, an analytical framework has
been created based on an investigation of case studies that are considered the best practices
in the field and that are considered to be successful projects given the positive externalities
generated toward their surrounding context and the revenues generated as a result of their
new functions [18,20]. The decision to ground this research on case studies [32] allows
for the detection of holistic and important characteristics of real-life processes. In this
context, the first step to carry out a coherent research study is to state a precise research
question for selecting an applicable sample of case studies. One of the most traditional
biases in applying this methodology in research is the generalization of detected results,
as explained by Lipset, Trow, and Coleman [33]: the final purpose is to perform a “gener-
alizing” and not a “particularizing” analysis, in fact the final goal should seek to expand
and generalize theories (analytic generalization) instead of enumerate frequencies (statical
Sustainability 2022, 14, 4712 4 of 18

generalization) [32]. By defining the borders of the research, it is simultaneously necessary

to underline some assumptions about the willingness to cover contextual conditions per-
tinent to the phenomenon of study. It allows for empirical investigation into a topic by
considering defined criteria.
Among the criteria for judging the quality of the research [32], in addition to validity,
is the reliability which is not related to the replicability of the process with different
case studies hoping to obtain the same results, but rather the achievement of the same
conclusions starting from the same analysis. In fact, the case study method suggests that
each case study can represent a complete study, where it is possible to detect evidence
provided by its conclusions, which could support the theory definition and the replication
by other individual cases [32].
Given this theoretical framework on case study research, and the objectives of defining
some common outcomes in the adaptive reuse of healthcare facilities, Figure 1 synthetizes
the steps developed in three specific phases in order to apply it:
1. Case studies analysis. A total of 12 cases of adaptive reuse of healthcare facilities have
been selected by considering certain criteria to guide the decision, such as:
i. Location: in order to provide a broader set of examples, they are located in
Italy, Europe, and Extra-EU;
ii. Year of the project: referring to recent interventions from the 2000s onwards;
iii. Owner: with a specific attention to public buildings;
iv. Assets: providing historical and cultural values from their features.
These four criteria worked as the main filter helping to identify the most suitable case
studies in relation to the purpose of the research.
2. Comparative analysis. A fact-sheet has been generated for each case study as well
as a final table to compare the characteristics analyzed. As we already explained,
criteria have been defined by considering the available information for understanding
the context, the building itself, the design concept, and the realized intervention of
adaptive reuse. These features have been selected with a set of experts in the field of
healthcare design and project appraisal.
3. Adaptive reuse evidence. According to the results of the previous steps, some conclusions
have been detected by considering the main issues analyzed and potential correlations.
In fact, this preliminary analysis allows us to understand if, according to the intrinsic
characteristics of the building and the extrinsic context, it is possible to suggest a
compatible set of adaptive reuse interventions.

Figure 1. Phases of the research. Figure designed by the authors.

Given the proposed steps, the processes developed can be conceived as a strategic tool
for analyzing case studies, elaborating on the data, and providing potential outcomes to
support Decision Makers (DMs) in selecting the most suitable and coherent alternatives of
adaptive reuse [34,35].
Sustainability 2022, 14, 4712 5 of 18

3. Case Study Analysis

Starting from the phases previously detailed within this section, the three steps will be
better explained and applied to the context under analysis regarding the adaptive reuse
of healthcare facilities. In particular, research has been carried out as part of the post
graduate master’s thesis of one of the authors [36] for the master’s program in “Planning,
Programming, and Design of Hospital and Healthcare Facilities” at Politecnico di Milano
(Polytechnic University of Milan), Università degli Studi di Milano (University of Milan),
and Università Cattolica del Sacro Cuore (Catholic University of the Sacred Heart) in
Rome [37].
The first step (Case studies analysis) examined former historic public hospitals that have
been recovered and reused in the last twenty years, as seen in Figure 2. In some cases,
these healthcare facilities were sold to private actors who developed conversion strategies
identifying their potential future use.

Figure 2. Case studies’ locations [36]. Figure designed by the authors.

Referring to the availability of useful information from journals, magazines, web

portals, and online pages, etc., the choice of the case studies considered the historical
and cultural values that they represented for the community and their preservation by
their respective bodies of protection. Thus, adaptive reuse becomes a concrete answer to
questions raised by a society increasingly attentive to the conservation of cultural heritage
but, at the same time, linked to an increasingly competitive model of economic development
and the circular economy. In fact, the economic growth of a country is based on the ability of
public institutions to reduce expenses, utilize its available resources, attract foreign capital,
and create jobs. These are all issues that the adaptive reuse line of research can address.
The list of selected architectures for this research are:
• Ex Ospedale Vighi (ex-Vighi Hospital) in Parma (Italy) was a multi-specialist hospital,
designed by the engineer Enrico Bovio in 1926, located near the ancient city walls.
After its abandonment, it was put up for auction and sold in 2004 and transformed into
a hotel [38,39]. Specifically, on the ground floor there is a banquet hall, the reception
area, the administrative offices, and the restaurant; the first floor hosts the suites,
and the rest of the rooms are located almost exclusively on the last floor. In total,
Sustainability 2022, 14, 4712 6 of 18

there are 70 rooms [39]. Outside, the green space has been redeveloped, respecting as
much as possible the existing trees. The entire building, in addition to maintaining its
architectural quality, was also equipped with the best technological solution for the
production of energy through a geothermal system [39].
• Ex Ospedale degli Innocenti (ex-Innocents Hospital) in Florence (Italy), built with
the intention of caring for and educating abandoned children, is one of the most
important achievements of Florence and more generally of the entire Renaissance. It
was designed by the architect Filippo Brunelleschi in 1445 [40]. In 2008, the building
was transformed into a museum [41]. The main purpose of the project was to give
rise to a museum for the city center, which would preserve the historical layout of
the building as much as possible. For this reason, the designed art gallery foresees a
“minimal” layout, characterized by inclined painted panels supported by aluminum
structures. The incline of these panels permits the museum to hide the installations
and to give depth to the museum paths. The selection of different construction and
finishing materials is consistent with the aim to respect the existing structure through
the use of wood, stone, and bronze [41].
• Ex Ospedale San Marco (ex-Saint Mark Hospital) in Venice (Italy) was built as a
healthcare facility for tuberculosis. It was built in 1870 and located in the artificial
island of Sacca Sessola in the South of the Venice lagoon. In 2010 the hospital was
transformed into a hotel with 230 suites and the other buildings into services for the
hospitality industry [42]. The masterplan reorganizes the island into three main parts,
marked by the green areas. In the area of the previous hospital, 230 suites have been
designed, while a terrace with a swimming pool has also been built [42]. Next to the
large monoblock, the church was converted into a conference center, while the hospital
director’s residence was transformed into a villa. All the pavilions have been recovered
and redesigned preserving the existing walls thus leaving historical features of the
original buildings intact [42]. The construction and recovery technologies involved the
use of steel and concrete within the existing brick walls and pre-fabricated wooden
structures. The old stables have been transformed into a spa [42].
• Ex Ospedale (ex-Hospital) in Lecco (Italy) was built as an extension of the historic
hospital at the beginning of the 20th century and it was dismissed in 2003. In 2010,
it was converted into department offices and a dormitory for Politecnico di Milano
in Lecco [43]. It is located in a rather large area of the city center with classrooms,
meeting rooms, and offices. The existing buildings (two mirrored pavilions) of the
existing hospital have been recovered and reused for department offices [43]. For the
reuse of the ancient structures, however, some interventions were necessary, such as
the addition of connections that guarantee the passage between the two halls and the
remaking of their large glass walls. The new L-shaped building rises two or three floors
above ground plus an underground floor which houses parking lots. The system of
open and closed courtyards tries to replicate the surrounding urban system, in which
existing buildings and new ones are closely related [43].
• Ex Ospedale Morgagni (ex-Morgagni Hospital) in Forlì (Italy) was built at the end
of the 1700s and after several enlargements during the first half of the 1800s it was
composed of seven pavilions. At the beginning of the 19th century, it was modernized
by the architect Tempioni. The hospital was abandoned in the 1970s and in 2000 a
competition was launched for the construction of a university campus (University of
Bologna) [44]. In general, the project considers the reconversion of three pavilions to
become teaching buildings with the introduction of a pedestrian path, immersed in
a dense green park over five hectares, and becoming an integral part of the city [44].
Another innovative aspect is related to the production of energy and heating of the
entire campus. It is guaranteed by a district heating and cogeneration system which
is currently the most efficient and green system. Great attention has been paid to the
choice of masonry packages to guarantee a relatively low sound transmittance and to
Sustainability 2022, 14, 4712 7 of 18

acoustic panels that guarantee a reduction of foot traffic noise up to 20 dB to preserve

the maximum soundproofing of study rooms and libraries [44].
• Ex ospedale Militare Hospital (ex-Military Hospital) in Catanzaro (Italy). The first hos-
pital settlement of the city of Catanzaro was erected in 1400 and was subsequently the
subject of numerous demolitions and volumetric additions, until the property passed
to the army in the mid-1800s. In the second half of the XX century the building was
dismissed [45] and after a public competition in 2010, it is currently being transformed
into the Italian Public Prosecutor’s Office [46]. The project, spread over four levels,
from the basement to the third floor, provides for the recovery of the ancient structures.
In particular, the intervention aims to realize a conservative restoration of the historic
building and the demolition of the buildings with a low artistic value that were built
after the original nucleus [46].
• Ex Ospedale del Mare (ex-Seaside Hospital) in Venice (Italy) is characterized by about
thirty buildings built in different periods starting from 1870. Over the years, it became
a reference point for the treatment of acute diseases, tuberculosis, etc., in the regional
context. The first pavilions were closed in the 1970s followed by a constant dismantling
of all departments due to a lack of maintenance which then led to its definitive closure
in 2003. The reconversion project of 2017 provides the recovery and reuse of almost all
the pavilions and the new construction of two buildings. It is expected to give rise to a
hotel, the construction of a new hospital block, an international tourism school, and a
wellness center [47].
• Ex Ospedale Psichiatrico (ex-Psychiatric Hospital) in Novara (Italy) was built in the
mid-1700s housing primary care and assistance services. The psychiatric hospital
was built a century later. It was enlarged little by little, expanding from 300 beds to
approximately 2000. Following the approval of the Basaglia law in Italy in 1978, the
structure began to be emptied and definitively closed in 1998. In 2007, the building
was converted into a community healthcare center for territorial health services [48,49].
The objective of the intervention was to restore and subsequently transform the former
psychiatric hospital into an integrated center for local health services. The new center
hosts district offices of the local health authority, a specialist outpatient clinic, and two
health care residences. In addition, in memory of the historical function of the hospital,
there is a center for psychiatric activities [49]. The management of the building was
defined through a Project Financing for a total duration of 27 years.
• Military Hospital in Toronto (Canada). In 1875 Smith and Gemmell designed a
Victorian-style building that hosted a Presbyterian seminary, a military hospital, and a
clinic. The structure was then converted into a clinic. It was abandoned and purchased
in the early 1970s, to become Knox College for the faculty of architecture and design in
Toronto [50]. The existing façade rises imposingly from the south, from which the large
access avenue branches off to the city. Precisely on this side, there is a new large glazed
curtain wall, whose stylistic rationality contrasts with a majestic brick building [50].
A very careful study of the green areas was developed with the use of native plants.
A sloping promenade, dug from the ground floor, leads students and teachers to the
lower level, where folding glass doors open to the classrooms. The recovery of the
historic buildings is visible from the east, in which there are classrooms, the library,
and offices. It is possible to see the merging of two different styles in which the gray
concrete panels connect with dark brick walls [50].
• Cook County Hospital in Chicago (USA). The first works began in 1834 and ended
in 1857, initially serving as a military hospital during the American Civil War. Later
it became the most important medical university in the country. In the early 1900s it
underwent important modernizations with collaboration with its doctors, becoming a
reference point for medical progress in the world [51]. In 2002, the hospital functions
were relocated into a new hospital and the building was dismissed. In 2018 the new
reconversion project has been approved which includes the construction of new offices,
restaurants, kindergartens, a museum, and a hotel with 210 rooms [52]. Despite the
Sustainability 2022, 14, 4712 8 of 18

abandonment, designers developed a recovery plan that would allow the façades
and openings, arches, and terracotta materials that enriched the historic façade to be
renovated. On the other hand, the interiors have been almost totally altered. The
original structure rested on clay arches; the material was then brought back to the
covering of the steel supporting columns [52].
• Richardson Olmsted Complex in Buffalo (USA) was designed by architect Henry
Hobson Richardson. The structure was a military hospital. In the 1970s, some pavilions
were demolished for new structures to treat psychiatric illnesses. During this time,
the campus was slowly abandoned. By 1973 it was added to the National Register
of Historic Places and in 1986 it was classified as a National Historic Landmark. In
2016, it was reconverted into a hotel with 88 suites [53]. The intervention provides
for the total recovery of the most significant historical parts, with a few volumetric
additions that allow the hotel to host 88 suites spread over more than 18,000 square
meters (sqm). In general, the building has been preserved, maintaining its red brick
walls, two large twin towers that overlook the structure, historical wooden stairs, and
decorations on the whole facade [53].
• Hôtel-Dieu in Lyon (France) was the first hospital in this city and it was built in the
XI century. Since its opening, it was one of the largest hospitals in France with nearly
400 beds. The hospital has always been closely linked to the history of the city of
Lyon and to the progress of French medicine. In fact, the great wars and famines
marked its morphological characteristics [54]. After the First World War, a museum
was inaugurated, but it continued its medical and university function throughout
the 20th century, until its final closure in 2010 and the transfer of its functions to the
new Hospices Civils de Lyon. In 2011, the Hôtel-Dieu was included in the list of
historical interest by the French government. Three years later the recovery and reuse
work began which, leaving the external morphology intact, mainly concerned the
division of the interior spaces into 150 luxury rooms, restaurants, bars, offices, and
conference centers [55]. The reuse project of the Hôtel-Dieu is part of the broader urban
redevelopment and recovery plan of the historic center of Lyon (France), well-known
as “Le Confluence” [55]. The proposed architecture takes into account the sobriety of
the interior spaces, and the majesty of the facades overlooking the Rhone. The idea
behind the project, as the designers stated, is expressed by the concept of “monastic
and precious”. In fact, the interiors have a great refinement of details, from the choice
of fabrics to the different prestigious finishing materials that change continuously in
any environment [55].
In the second phase (Comparative analysis), hospital analysis was supported by a fact-
sheet where primary essential data was reported together with one or more representative
pictures, plans (when available), and a brief description of the adaptive reuse project with
detailed information on the intervention (the conservative actions, the design strategies,
etc.). Figure 3 presents an example of the analysis developed for historical Hospital in
Lecco (Italy).
The recovery and reuse projects examined consider specific aspects that have been
synthetically reported in a table divided into “pre” and “post” adaptive reuse’s actions.
The geographical location and the map of the territorial framework identify the spatial
location. The historical function describes the healthcare activity of the building before the
intervention, while the current function represents the use for which it has been designed.
Mentioning pre and post features is essential to understand the design choices of the
historic building and at the same time to know the architectural intentions of recovery.
This topic is connected to that of historical buildings and intervention typologies. Hospital
building evolution is one of the most studied topics in the planning field, as it is strictly
connected to the destination of health care and the change and progress of health care
systems. In fact, history has witnessed a typological change, shifting from a planimetric
scheme mainly based on pavilions to one based on a single block, or other hybrid solutions.
The case studies analyzed, in detail, present two typologies: the monoblock, characterized
Sustainability 2022, 14, 4712 9 of 18

by a compact structure, and the pavilion, divided into several buildings not connected
among them.

Figure 3. Fact-sheet of case study analysis [43]. Figure designed by the authors; the images are from
the website of Politecnico di Milano and the map is based on Google Maps.

In the list of criteria used to describe each case study, the intervention typology has
been investigated: the choice of adaptive reuse adopted by the designer of the recovery,
which can be conservative or partially conservative (e.g., total preservation of the building
and/or the addition of new volumes).
Moreover, the years of realization and disposal of a building allow for understanding
architectural style (or styles), the possible criticalities and potentialities, and if it can be
included among the protected goods.
No less important is the economic issue, which highlights the costs of recovery and
reuse of historical assets, thanks to which it is possible to estimate the cost per square meter
of each case study proposed.
Figure 3 shows one of the fact-sheets developed to analyze the set of case studies, on
the left side, informative data have been presented by underlying the differences among
historical and current characteristics of the building, while on the right side, it is possible to
appreciate a more detailed description.
Once all the case studies have been analyzed by considering the criteria elicited, it
has been possible to give rise to a comparative analysis to understand possible trends and
guidelines to support the definition of the most suitable adaptive reuse function.
Table 1 synthesizes all the data collected with historical information presented in black
and current information in red.
Sustainability 2022, 14, 4712 10 of 18

Table 1. Comparative analysis [38–56]. Table structured by the authors (in black historical information, in red the current information).
Hospital Location Historocal Designer Historocal Year of Construc- Year New Interven- Historical Historic GFA/Current Building Typology N◦ Of Beds Intervention Cost of the
Function/Current Context/Current tion/Disposal tion/Inauguration Dimension of the GFA Typology Intervention
Function Context Areas/Current (EUR)

ex ospedale Vighi Parma, Italy multi- Enrico Bovio/Giandebiaggi peripheral/city 1926/2010 2010/2013 10000 sqm/10000 6800 sqm/6800 sqm monoblock n.a. conservative 3,500,000
specialist/hotel centre sqm recovery

ex ospedale degli Florence, Italy multi- Filippo Brunelleschi/Ipostudio city centre/city 1445/1890 2010/2016 6000 sqm/6000 sqm 5200 sqm/5200 sqm monoblock 250–300 conservative 12,800,000
Innoccenti specialist/museum centre recovery

ex ospedale San Venice, Italy tuberculosis/hotel n.a./Matteo Thun CZstudio Sacca Sessola Island 1936/1979 2010/2016 160,000 sqm/160,000 32,000 sqm/32,000 sqm pavillions 300–450 partially 120,000,000
Marco sqm conservative
recovery

ex ospedale Lecco Lecco, Italy multi- n.a./Paolo Bodega city centre/city 1930/2003 2010/2013 18,000 sqm/18,000 n.a./5500 sqm (existing) pavillions 80 recovery with 51,000,000
specialist/university centre sqm + 12,000 (new) volumetric increases

ex ospedale Forlì, Italy tuberculosis/hotel Giovanni Tempioni/Lamberti city centre/city 1916/1973 2010/2016 90,000 sqm/90,000 23,000 sqm/22,600 sqm pavillions n.a. recovery with 28,000,000
Morgagni Rossi centre sqm (existing) + 13,000 (new) volumetric increases

ex ospedale Militare Catanzaro, Italy military n.a./Corvino + Multari peripheral/city 1850/second half 2010/under contract 5000 sqm/5000 sqm 6200 sqm/6237 sqm monoblock n.a. conservative 9,000,000
hospital/offices centre ‘900 recovery

ex ospedale al Mare Venice, Italy tuberculosis/hotel several Lido of Venice 1933/2003 2017/under contract 140,000 sqm/140,000 n.a./40,000 sqm pavillions around 1400 partially 132,000,000
designers/Piva+Rosselli sqm conservative
recovery

ex ospedale Novara, Italy psychiatric/offices Lucca/Cobolli Gigli peripheral/city 1875/1978 2005/2007 170,000 sqm/170,000 n.a./14,000 sqm pavillions around 2000 partially 56,000,000
Psichiatrico centre sqm conservative
recovery

ex ospedale Militare Toronto, Canada military Smith&Gemmel/NADAAA peripheral/city 1875/1972 2013/2018 9000 sqm/9000 sqm n.a./6500 sqm polyblock n.a. recovery with 63,000,000
hospital/university centre volumetric increases

Cook County Chicago, USA multi- County, Gerhardt/SOM city centre/city 1834/2002 2018/under 12,000 sqm/12,000 15,000 sqm/15,000 sqm polyblock 470 partially 153,000,000
Hospital specialist/hotel + centre construction sqm conservative
mix functions recovery

Richardson Olmsted Buffalo, USA multi- Henry Hobson peripheral/peripheral 1870/2002 2014/2016 380,000 sqm/380,000 n.a./18,000 sqm pavillions n.a. recovery with 90,000,000
Complex specialist/hotel Richardson/Deborah Berke sqm volumetric increases

Hôtel-Dieu Lyon, France multi- several city centre/city 1710/2010 2014/2018 20,000 sqm/20,000 51,000 sqm/51,000 sqm polyblock 500 partially 250,000,000
specialist/hotel + designers/Costantin+Nuel centre sqm conservative
mix functions recovery
Sustainability 2022, 14, 4712 11 of 18

4. Results and Discussion

The comparative analysis previously developed allows to detect possible correlations
between the different criteria that have been analyzed and systematized.
Regarding the relationship between the historical building typology and interven-
tion typology, it is possible to recognize mainly three typologies: tuberculosis, multi-
specialty/military, and psychiatric hospitals.
It is not possible to underline trends or similarities among the previous and current
functions. However, most tuberculosis hospitals currently host private services (e.g.,
hotels), while most multi-specialty/military ones offer public services (e.g., universities
and museums). Psychiatric hospitals host in equal part private and public services [56].
Moving the attention to the building’s location, and if its proximity to the city center
could influence its function [57], it is possible to detect a strong connection with the
historical function but not with the current one. In fact, the only hospitals to be built
in the suburbs are tuberculosis and psychiatric sites. The reasons are rather obvious: in
fact, their function was to ensure adequate care for tuberculosis patients, allowing them
to breathe clean air and enjoy maximum sunlight [2]. There are many other European
examples of sanatoriums built in mountainous areas or near the sea, but in both cases, they
are characterized by large openings and large terraces oriented towards the south-east [58].
Psychiatric hospitals were also primarily located in peripheral areas, although for social
rather than medical reasons [59].
The study of hospital building typologies provides insight into the planimetric de-
velopment of the analyzed case studies concerning the current functions that they are
required to respond to. By looking at their plans, it can be observed that all of them have a
horizontal development, and their building typology can be divided into monoblock (com-
pact building typology), polyblock (several buildings connected), and pavilions (several
buildings separated from each other) [27]. Looking specifically at the relationship between
their current functions and their floor plan, the four monoblock structures have different
functions (university, hotel, offices, and museum), the two polyblocks have been reused
as universities and hotels with a functional mix, and the previous pavilion hospitals have
mostly been transformed into facilities for hospitality.
The links between the various topics covered uncover valid relational data to hypothe-
size possible uses of abandoned health facilities. The case studies treated, though limited in
number, have provided data and correlations. In addition, they show a close relationship
between the type of intervention and the cost of recovery. This correlation has emerged
mainly through the gross floor area (GFA) cost per square meter. Table 1 shows a higher
cost for interventions that provide volumetric increases, while costs tend to be lower for
totally or partially recovered structures.
Although each former hospital has unique intrinsic and extrinsic features, their recov-
ery and reuse have shown common concepts. Initially, three types of historical functions
were defined: tuberculosis, the multi-specialty and military, and the psychiatric ones. Their
closure and subsequent abandonment caused urban and social degradation problems be-
cause, in most cases, their activities had a great value not only considering the well-being
but also economic and social ones for the entire community. Thus, their abandonment has
transformed them from care spaces to non-places, deprived of their function and historical
memory [17,60]. Their reactivation has become an open issue that has been debated in
some cases for years by the various local administrations that have tried to promote the
reuse by dialoguing with other public bodies or private subjects. The previous estimation
of the costs per square meter has shown that the economic availability is greater when
interventions involve private subjects. This relation results in one of the most interesting
among these studied: a more significant investment can result in more economic income
for the entire system. In addition, the most evident relationship is the one that compares
the current function and the relationship between the surface of the area and the covered
surface.
Sustainability 2022, 14, 4712 12 of 18

Some functions seem to prioritize a more excellent ratio of uncovered to covered

area. Whether located in peripheral or central areas, hotels and universities have shown
a high free space area. This ratio is directly related to the historical building typology. In
fact, the pavilion buildings were realized on large areas (mainly located in the peripheries
of the consolidated urban fabric) while the other typologies, monoblock and polyblock,
were located in central or semi-central areas. On the other hand, the type of intervention
and current function is closely correlated with recovery costs, confirming the importance
of sustainable adaptive reuse and the need for constant maintenance to preserve the
degradation of the property.
Table 2 summarizes the different levels of relationship, divided into high, medium, and
low, which allows to synthesize and clarify what has been described. In the decision-making
phase, although a series of different variables can have an important role (geographical
location, available budget, or territorial vocations), the summary table of the correlation
can be a helpful tool to understand if the hypothesis of adaptive reuse may be suitable in
respect to the building under evaluation [36].
Some of the correlations are related to historical characteristics of the buildings while
others can be read as consequences of the decision taken. In fact, the original layout strongly
affects the possible adaptive reuse functions while the interventions proposed have direct
impacts on sustained costs. Usually, private developers are more inclined to face a higher
risk in the investment that corresponds to a higher return [61]. According to the cases
analyzed and from examining the real-estate market, the most profitable functions are
private ones, such as hotels, offices, etc., which correspond to the functions proposed by
private actors.
Figure 4 represents a first attempt to support DMs in taking a decision about the
adaptive reuse of healthcare facilities or at least to show the outcomes of existing case
studies. On the left side of the graph, the criteria analyzed for each building are presented
with the different options, while on the right side the new functions identified are listed.
According to the location, the typology, the ratio between GFA and covered surface area,
the intervention typology, and the possible cost, several suitable alternatives of adaptive
reuse could be selected.
Starting from Figure 4 and the work by Scalone (2020) [36], the best practices, subdi-
vided into the common public and private facilities, have been listed in Table 3.
According to the investigation, in the example of universities as reuse functions, it
is suggested for the building to be located in the city center, to be organized in pavilions,
and usually it is necessary to perform a partially conservatory intervention of recovery
with an approximate cost estimation in between 800 and 3000 EUR/sqm [36]. For the
museum, also in this case, it should be in a central location with a monoblock typology.
The recovery intervention could be conservative and cost the same as the previous function.
The most expensive cost estimations per sqm are related to the private functions, i.e., hotel
or hotel with a mix of functions. In fact, their restoration concerns also the addition of other
buildings, i.e., volumetric increase, but they could be located in peripheral contexts and
organized in polyblock.
Sustainability 2022, 14, 4712 13 of 18

Table 2. Correlation table (••• high, •• medium, • low) [36]. Table designed by the authors.

Historical Current Context DIMENSION GFA Area / CS Building Intervention Cost of the Cost Stakeholders
Function Function AREA Typology Typology Intervention EUR/sqm
Historical ••• •• •• •• ••
function
Current function •• • •• ••• •• •• • • •••
Context ••• ••• •• ••
Dimension area ••• ••• ••• ••• ••• •••
GFA •• •• ••• •••
Area / CS ••• •• •
Building •• •
typology
Intervention ••• ••• •••
typology
Cost of the ••• •••
intervention
Cost €/sqm •••
Sustainability 2022, 14, 4712 14 of 18

Figure 4. Adaptive reuse strategies [36]. Image designed by the authors.

Table 3. Best practices subdivided into the common public and private facilities [36]. Table structured
by the authors.

Hotel with Urban

University Museum Office Hotel
Services
Localization City center City center City center Suburbs Suburbs
Building typology Polyblock Monoblock Monoblock Pavilion Pavilion
GFA/covered
From 1 to 5 From 1 to 5 From 1 to 5 From 5 to 50 From 5 to 50
surface area
With possible With possible
Type of Partially
Conservative Conservative volumetric volumetric
intervention conservative
increases increases
Up to 3000 Up to 3000 Up to 3000 More than 3000 More than 3000
Intervention costs
EUR/sqm EUR/sqm EUR/sqm EUR/sqm EUR/sqm
Ex ospedale degli
Ex ospedale Ex ospedale degli Ex Richardson
Reference Militare in Hôtel-Dieu
Morgagni Innoccenti Olmsted Complex
Catanzaro

According to the results obtained, it is clear the strong correlation between the recovery
intervention and the cost estimations but what could be better underlined is the adaptive
reuse decision that is strongly influenced not only from the location of the building but
from its typology. In fact, the internal organization of the spaces has a huge impact on the
future function to be hosted. The monoblock typically corresponds to the subdivision of the
different functions in the various floors and this layout matches the common organization of
public and cultural buildings such as museums. Conversely, the arrangement in pavilions
allow for better separate spaces, functions, and levels of privacy. This layout aligns with the
need of a university campus given by its necessity to have several classes, administration
offices, cafeteria, etc. To conclude, the polyblock, a model that includes a small number of
grouped and connected buildings, gives the possibility to easily reach all the floors and
buildings while providing an appropriate level of privacy, features that perfectly match the
Sustainability 2022, 14, 4712 15 of 18

organization of offices or hotel. If the building is already suitable to host a new function
without too many construction changes to the layout, the final cost and time of the overall
intervention will have a lower impact compared to a complete recovery work.
These preliminary outputs can be expanded with the investigation of other case
studies. It has been stated by Robert K. Yin (2003): “multiple-case designs may be preferred over
single-case designs. Even if you can only do a two-case case study, your chances of doing a good
case study will be better than using a single-case design. Single-case designs are vulnerable [ . . .
]. More important, the analytic benefits from having two (or more) cases may be substantial” [32].
Moreover, since the final purpose is to do a “generalizing” and not a “particularizing”
analysis, these first conclusions serve as a starting point for creating guidelines useful in
finding satisfactory trade-offs among all the involved dimensions, and in investigating the
relation between cost and benefits of a new intervention.

5. Conclusions
Although the number of case studies is limited, the research work carried out high-
lights how the recovery and reuse of abandoned buildings is an emerging issue, beginning
from several successful experiences. For this reason, local administrations are promoting
several policies to incentivize actions aimed at enhancing the building heritage and, more
generally, urban regeneration. To improve this scope, it is necessary to involve citizens,
who can become a useful instrument in the decision-making process [62,63], helping to
make truly desired choices in the public domain for the whole community.
The regeneration of hospital facilities is also linked to the issue of safeguarding the
heritage of historical real estate. Their dimensions, although they vary for each case study,
have been an opportunity or a great limitation. Despite the desire to regenerate them, public
or private actors have clashed with resulting high recovery and management costs [64,65].
The analysis of the case studies has determined a series of correlations useful for
tracing possible models of regeneration of abandoned hospital structures.
The collaboration between public and private subjects shows that, if certain conditions
arise, it becomes a useful tool for the efficiency of the recovery and reuse process given the
potentiality of Public–Private Partnership (PPP) [66]. However, public institutions should
accompany the development of project proposals, in order to avoid the implementation of
policies contrary to a sustainable transformation process [13].
The analytical study has also allowed to compare design aspects, which have shown
different design approaches and the heterogeneous cultural and stylistic forms. Despite
the expressive differences, the analysis highlights a common will to preserve the historical
memory and identity even when removing the socio-sanitary functional trace.

Author Contributions: Data curation, M.G., M.D. and S.S.; formal analysis, S.S.; investigation, M.G.,
M.D. and S.S.; methodology, M.G. and M.D.; project administration, S.C.; supervision, S.C.; writing—
original draft, M.G. and M.D.; writing—review and editing, M.G., M.D., S.S. and S.C. All authors
have read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Acknowledgments: The authors are grateful with the reviewers for their useful comments, aimed at
improving the quality of the contents of the paper. In addition, the authors thanks Alexander Achille
Johnson for his support and review of the English editing.
Conflicts of Interest: The authors declare no conflict of interest.
Sustainability 2022, 14, 4712 16 of 18

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