The Imperative for Change – Designing for the Changing Ambulatory Healthcare Delivery Model

White Paper

THOUGHT LEADERSHIP

THE IMPERATIVE FOR CHANGE PLANNING AND DESIGN FOR THE CHANGING AMBULATORY HEALTHCARE DELIVERY MODEL KATHY CLARK RN, BSN, MHA TERRY THURSTON RN, BSN, MBA PHIL CARTWRIGHT AIA, ACHA, EDAC, LEED AP SEPTEMBER 2013

W H I T E P A P E R | SEPTEMBER 2013

The Imperative for Change It’s not business as usual - a new platform is being built for healthcare, as the system resets itself for a new delivery model. Not since the Hill Burton era, have government actions impacted the healthcare built environment as they do today. On January 1, 2014 millions of Americans who have relied on emergency rooms and free clinics for primary and urgent care will now be required, by way of the Affordable Care Act, to enroll in some type of basic insurance coverage. Patients are not coming just for care, but rather to be placed in a system that is expected to manage their health and keep them well. There is a sense of urgency to address this issue from both an operational and built environment standpoint.

We can no longer think of healthcare systems as a series of silo services ranging from hospitals to clinics and outpatient centers.

With tremendous pressure on healthcare organizations to develop systems of care inclusive of health and wellness programs, our challenge is to create a framework for the supporting facility infrastructure which is adaptable, responsive and flexible to the ongoing changes of the healthcare environment. The solutions to this swell of patients are not simple and we cannot solve this problem by simply building without a framework or strategy.

The intent of this paper is to convey the concepts behind the various models and typologies of ambulatory care. The future will demand a combination of models that offer an approach to facility planning that evolves and adapts to the changing marketplace. An operational case study is also included in this white paper to express tactics for maximizing the utilization of ambulatory spaces.

Healthcare services and the facilities they are offered in are, by necessity, changing. The new model focuses on more than just providing medical office buildings and clinic space in convenient locations. Healthcare organizations need to focus on the wellness and management of a patient’s health throughout the continuum of care.

2

© BSA LifeStructures / Use of reprint not allowed without expressed consent from the author

SEPTEMBER 2013 | W H I T E P A P E R

POST-ACUTE CARE

AMBULATORY CARE

INPATIENT CARE

POST-ACUTE CARE

INPATIENT CARE

AMBULATORY CARE

TODAY’S HEALTHCARE

TOMORROW’S HEALTHCARE

Individual Patient Management

Population Health

PCP Sole Provider of Patient Care

Collaborative Care Team (Integrated Patient Management & Patient Centered Medical Home)

Fixed Spaces

Flexible Spaces

Evolving Technology

Technology-Driven Care

Ambulatory Care Staff Separate From Hospital Staff

Hospital Staff Repurposed For Ambulatory Care

Patient Compliance is Self-Initiated, Self-Directed

Community Health Teams Providing: Screenings, Medication Management, Connect Patients with Community Resources

Patients without a PCP are Unattended or Utilize Hospital ED

TeleHealth and Clinics on Wheels

Office/Care Delivery Space Typically in MOB

Use of “After Hours” Space in Churches, Schools, Retail Space, Employer-Based Clinics

Episodic Care

Continuity of Care

PCP on Hospital Campus

PCP out in Community

© BSA LifeStructures / Use of reprint not allowed without expressed consent from the author

3

W H I T E P A P E R | SEPTEMBER 2013

Resetting the U.S. Healthcare Built Environment

Primary Access Portal: Retail, Offices, Urgent Care

The traditional healthcare built environment is being transformed by technology, electronic information systems and universal coverage. One of the strongest trends is the creation of alternatives to inpatient care. From incentives to penalties, the focus is not just on caring for patients in alternative settings, but on keeping patients healthy. Expanding the ambulatory market is the primary focus. The built environment surrounding the ambulatory segment will be completely different than previous initiatives as large construction projects give way to renovations and the repurposing of existing space.

Mobile: Visits on Wheels, Clinics in Churches, Schools, etc.

VIRTUAL PATIENT CARE: iTriage, VGo, Real Time Monitoring

The healthcare model will continue to evolve and will feature many more permutations before it settles, thus the need for nimble responses and flexible design.

Specialty and Diagnostic Treatment

Comprehensive: ASC with Observation Beds

Changing the Model In light of constrained capital, healthcare organizations will need to plan the development of their ambulatory strategy very carefully (location and type of facility). A single ambulatory facility typology will not fit every organization; likewise, a given organization should consider various typologies to be part of their portfolio of ambulatory care facilities in order to meet a variety of needs.

LARGE “DOWNTOWN” BANK BRANCH BANK

ATMs

The banking industry has undergone tremendous change over the years and, in many ways, the healthcare industry is following suit. The “window to the future” could easily look like this:

4

LARGE URBAN HOSPITAL

BRANCH BANK

ATMs

ATMs

ELECTRONIC BANKING

SUBURBAN/ SATELLITE HOSPITALS AMB. CTRS.

SUBURBAN/ SATELLITE HOSPITALS

AMB. CTRS.

AMB. CTRS.

VIRTUAL MEDICINE

© BSA LifeStructures / Use of reprint not allowed without expressed consent from the author

SEPTEMBER 2013 | W H I T E P A P E R

Ambulatory Care Typologies Summary Matrix MICRO-CLINIC

MOB +

MULTI-SPECIALTY CLINIC

CLINIC WITH OBSERVATION BEDS 26+

PROVIDERS

1

2-5

6 - 10*

11 - 25

EXAM ROOMS

3

6 - 15

15 - 27

27 - 63

63+

3:1 Exam - Provider

3:1 Exam - Provider

2.75:1 Exam - Provider

2.75:1 Exam - Provider

2.5:1 Exam - Provider

< 2,000 GSF

2 - 10,000 GSF

10 - 15,000 GSF

15 - 50,000 GSF

50 - 100,000 GSF

• Full Scale Lab • Advanced Imaging • Rehab • Urgent Care • ASC • Pharmacy

• Full Scale Lab • Advanced Imaging • Rehab • Freestanding Emergency Dept.

• ASC • Pharmacy w/ DME • Oncology Services • Observation Beds • Wellness

EXAM ROOMS: PROVIDER* SIZE

INCLUDED SERVICES

TEAM POSSIBLE ADD-ONS

PCP OFFICE

PATIENT-CENTERED MEDICAL HOME

Treat minor illnesses & injuries, monitor chronic conditions + general health screenings & vaccinations

• Comprehensive care, limited lab testing, biometric screening, annual physicals • Basic Lab

Mid-Level Provider

+ Primary Care Physician, RN / LVN, MA, Social Worker, Patient Navigator

• Basic Lab • Basic Imaging • Limited Rehab • Pharmacy

+ Diabetes Educator, Dietician, Pharmacist, Behavioral Health Specialist, PT/OT

+ Medical Specialists

+ Additional Medical Specialists

Education, group visit appointments, family focus = additional space in select locations [ i.e. waiting rooms and exam rooms], consultation, patient navigators, team-based collaborative work space, robust IT systems including EMR and Tele-medicine e-visits

INFUSION SERVICES

x

x

x

x

URGENT CARE OBSERVATION RETAIL PHARMACY

x

* As the number of providers increase, less dedicated rooms per provider are needed due to diverse scheduling options.

The Ambulatory Care Typology Summary Matrix above provides details on the various types of ambulatory care settings and offers a guideline for the potential services in each.

© BSA LifeStructures / Use of reprint not allowed without expressed consent from the author

5

W H I T E P A P E R | SEPTEMBER 2013

Facility Considerations for the New Model of Ambulatory Care The facility considerations below should be examined when planning new ambulatory facilities.

1 1.

Healthcare new construction will be focused on providing right-sized primary care facilities.

2.

2

The shift to managed contracts and clinic-based care will mean a smaller “mother ship” surrounded by a system of community clinics, smaller tertiary clinics and retail clinics.

3.

3

Ambulatory facilities will be decentralized reaching deep into the community providing convenient access.

4.

4

“Loose fit” – designing extra space into a room or department to accommodate future adjustment.

5.

5

Utilize universal room design for like or similar uses.

6.

6

Utilization of waiting spaces for education.

hours per day, five days per

7 7.

Provide intuitive wayfinding with effective signage that includes efficient patient movement.

8.

8

Include multi-function spaces with appropriate equipment and supplies readily available.

week. It is critical to plan am-

9.

9

Design must facilitate and encourage team-based care and patient driven programs for a comprehensive medical home (inclusive of collaboration spaces and technology (EHR and video conferencing).

We can no longer continue to afford 10,000 to 100,000 square feet of space to only be operational eight to 10

bulatory settings strategically and be creative with both operations and staffing.

10.

Flexible and adaptive spaces (group exams, education and wellness programs).

10 11.

Emphasis on patient safety, lean workflow and low cost.

11 12.

Develop a loose framework that can flex to fit an array of future and/or simultaneous needs (see case 12 study on following page).

13.

Accommodations for the obese and aging population which translates to access. Minimized walking 13 distances and room size.

6

© BSA LifeStructures / Use of reprint not allowed without expressed consent from the author

SEPTEMBER 2013 | W H I T E P A P E R

Case Study Traditionally, if an organization was going to develop primary care, multi-specialty office practices, urgent care, ambulatory surgery or observation beds, these services might have been co-located on the same campus or located as stand-alone services in separate facilities on various sites. But what if we developed flexible space to accommodate all of these services in an over-lapping, universal

• The physician office practice hours of operation will be from 8 a.m. to 6 p.m.

• The Urgent Care’s hours of operation could be from 6 p.m. to midnight • The ASC’s hours of operation could be from 5 a.m. to 6 p.m.

• The Observation Unit would be open 24/7

SPACE

SPACE

0:00 1:00 2:00 3:00 4:00 5:00 6:00

Urgent Care

Ambulatory Surgery Center

Prep & 2nd Stage Recovery

Observation Beds

3

4

5

By combining the primary care practice and urgent care, percent utilization is increased by

60%

2:00 3:00 4:00 5:00 6:00

Using the above as a traditional model, sharing space could substantially improve the overall utilization and efficiency of the

8:00

available space. Assume a 40,000 square foot facility of which:

10:00

12:00

8 a.m. to 6 p.m.

• Urgent Care occupied this exact same space from 6 p.m. to midnight, Monday through Friday, Saturday and Sunday 10 a.m. to 10 p.m.

• ASC comprises 20,000 square feet from 5 a.m. to 6 p.m.

Monday through Friday • Observation beds comprised of 5,000 square feet, 24/7, Monday through Friday • Between 5 a.m. to 6 p.m. a specific number of observation beds would be used for prep and second stage recovery.

13:00 14:00 15:00 16:00 17:00

Co-locating the ASC’s prep and second stage recovery with observation beds increases the utilization of this space by

71%

9:00 10:00 11:00 12:00 13:00 14:00 15:00 16:00 17:00

18:00

18:00

19:00

19:00

20:00

20:00

21:00

21:00

22:00

22:00

23:00

23:00

© BSA LifeStructures / Use of reprint not allowed without expressed consent from the author

3

1:00

7:00

• Physician offices comprise 15,000 square feet from

SPACE

2

0:00

8:00

11:00

SPACE

1

7:00

9:00

SPACE

Prep & 2nd Stage Recovery & Observation Beds

SPACE

2

Ambulatory Surgery Center

SPACE

Physician(s) Office Practice & Urgent Care

SPACE

1

facility? Here’s what we could assume:

Future

Physician(s) Office Practice

Traditional

7

W H I T E P A P E R | SEPTEMBER 2013

Approach The ambulatory imperative requires an organized strategy. We have listed some of the key steps to plan for tomorrow’s ambulatory care environment:

11.

Assess the current state operations which include an inventory of all services that are or could be provided in an ambulatory care setting.

2 33.

44.

Conduct data analysis, including population health statistics, to determine the right services at the right place at the right time for the population to be served.

2.

Test the assessed needs against the different typologies listed above.

Plan and design the built environment for patient access and flow, the continuum of care and future flexibility for maximum use of space.

The following images are adjacency diagrams used to demonstrate how initial planning and placement could enable future growth and maximize space. These diagrams represent usable space and the relationship between those spaces. The actual footprint/floor plan of the facility could take many forms by following the principles established by these diagrams. The central theme of these diagrams is the use of a “central spine” onto which different components (services) can be added. The primary benefit of planning an ambulatory campus in this manner is to promote and enable connectivity, shared use of space and to allow for future growth.

8

© BSA LifeStructures / Use of reprint not allowed without expressed consent from the author

SEPTEMBER 2013 | W H I T E P A P E R

Diagram 1

Diagram 1 conveys (in green, pink and red) the components of a primary care office practice of 3 PCP’s (Note: This could also be referred to as a patient centered medical home). New space types include: a) talking rooms (consultation rooms), b) virtual health lab for patient at home monitoring, c) lab and pharmacy, and d) conferencing and office space for care coordinators and social workers. Rather than closing this area at 5 p.m., this space can become occupied and operate as an urgent care facility.

Diagram 2

If expansion on this site was desired for an ambulatory surgery center (represented in purple), Diagram 2 conveys the attachment point. The opportunity to maximize space is also available with the addition of the ambulatory surgery center. A portion of the prep/recovery space could also be used for observation care.

Diagram 3

Diagram 3 demonstrates how expansion (blue) could occur for additional surgery space, clinic space or new growth for additional service lines. Here again, the relationship to the “central spine” ensures continuity and congruent relationships and instinctive paths of travel rather than the traditional approach of placing various individually purposed ambulatory sites or continuously adding on to a building, which over time, become disjointed and inefficient.

© BSA LifeStructures / Use of reprint not allowed without expressed consent from the author

9

Austin | Chicago | Indianapolis | St. Louis www.bsalifestructures.com 800.565.4855

BSA LifeStructures designs facilities that support, enhance and inspire healing, learning and discovery. Facilities that are lifestructures.

KATHY CLARK RN, BSN, MHA kclark@bsalifestructures.com

TERRY THURSTON RN, BSN, MBA tthurston@bsalifestructures.com

PHIL CARTWRIGHT AIA, ACHA, EDAC, LEED AP pcartwright@bsalifestructures.com