Ambulatory Facility
Strategy in the Reform Era
Michael Hubble
Senior Director
The Advisory Board Company
hubblem@advisory.com
FACILITY PLANNING FORUM
© 2011 The Advisory Board Company • www.advisory.com
2
Road Map for Discussion
I
II
Playing by Different Rules
Rethinking Ambulatory Facility Strategy
III
Rethinking Ambulatory Facility Design
IV
Migrating to a Patient-Centered Model
© 2011 The Advisory Board Company • www.advisory.com
3
Hospital Outpatient Strategy circa 2007
Health Systems Placing Big Bets on Ambulatory Expansion
Planned Hospital Expansions
Within Next Two Years
Principal Drivers of
Outpatient Investment
n=199
Capturing profitable
outpatient business in
new markets
Neither
Outpatient
16%
Inpatient
4%
34%
Creating new feeders for
the inpatient enterprise
46%
Both
80% of hospitals
were planning
outpatient
expansion
© 2011 The Advisory Board Company • www.advisory.com
Blunting competition from
physician-owned facilities
Building a platform for a
future inpatient facility
Source: Bank of America, “Health Care Facilities,” Equities
Research, July 2007: Advisory Board interviews and analysis.
4
Hard to Believe It Was Just 2 Years Ago…
From Health Care Reform to Payment Reform
Major Reform Milestones
Patient
Protection and
Affordable Care
Act (PPACA)
passes House of
Representatives
HHS releases
Meaningful Use
regulations
VA Attorney
General files first
lawsuit against
individual mandate
© 2011 The Advisory Board Company • www.advisory.com
President
Obama repeals
1099 reporting
requirement
from PPACA
CMS releases
proposed rule for
Medicare Shared
Savings Program
CMS issues
provisions to
Hospital
Readmissions
Reduction
Program
HHS releases
Medicare ValueBased Purchasing
Program final rule
Source: Health Care Advisory Board interviews and analysis.
5
Health Insurance Reform
Virtually Eliminating the Uninsured
Massachusetts Universal Coverage Initiative
Cumulative Increase in Insured
Massachusetts Residents
Massachusetts Coverage
Expansion
Thousands
425
367
421
202
Jan-09
Oct-08
Jul-08
Apr-08
Jan-08
Oct-07
Jul-07
Apr-07
Jan-07
114
87% of coverage expansion achieved by January
2008, one year after exchange became available
© 2011 The Advisory Board Company • www.advisory.com
• Implemented July 1, 2006; reduced uninsured
rate to 2.6%
• Individual and employer mandates established
• Individual penalty initially set at $219 with
monthly incremental increases
• Employer penalty at $295 annually per employee
• Individual and small group markets merged,
managed through online “exchange”
• New publicly managed insurance options created
• Charity care funds reallocated from
disproportionate share payments to
coverage subsidies
Source: Division of Health Care Finance and Policy, “Health
Care Indicators in Massachusetts,” November 2009; Health
Care Advisory Board interviews and analysis.
6
Preventive Care Utilization Has Increased…
Utilization of Specific Services, Massachusetts Adults
Based on Self-Reported Data, 2006-2009
n = 13,150
78%
Preventive Care
70%
58%
55%
53%
51%
34%
Fall 2006
34%
Fall 2007
Fall 2008
Preventive Care
Specialist Visit
Took Any Rx Drugs
Any ED Visit
Took Any Drug
Specialist Visit
ED Visit
Fall 2009
Percent Change
in Utilization
9.6%
Preventive Care
4.1%
Took Any Drug
5.5%
Specialist Visit
(0.5%)
ED Visit
© 2011 The Advisory Board Company • www.advisory.com
Source: Long S and Stockley K, “Sustaining Health Reform in a Recession:
An Update on Massachusetts as of Fall 2009,” Health Affairs, June 2010
29:6 1234-1240; Health Care Advisory Board interviews and analysis.
7
Payment Reform
Toward Accountable Care
Building Accountability through Experiments in Payment
Capitation/Shared-Savings Models
Episodic Bundling
Degree of
Shared Risk
Hospital-Physician
Bundling
Pay-forPerformance
Care Continuum
© 2011 The Advisory Board Company • www.advisory.com
Source: Health Care Advisory Board interviews and analysis.
8
Biggest News of the Year?
Medicare Shared Savings Program Holding Providers Accountable
Shared Savings Payment Cycle
Program in Brief: Medicare
Shared Savings Program
• Program begins January 1, 2012; contracts
to last minimum of three years
• Physician groups and hospitals eligible to
participate, but primary care physicians
must be included in any ACO group
• Participating ACOs must serve at least
5,000 Medicare beneficiaries
• Bonus potential to depend on Medicare
cost savings, quality metrics
• Two options available: one with no
downside risk until year three, the second
with downside risk in all three years
• Proposed rule available for comment until
end of May; final rule due later this year
© 2011 The Advisory Board Company • www.advisory.com
Assignment
Patients assigned to ACO
based on terms of contract
Billing
Providers bill normally,
receive standard fee-forservice payments
1
2
3
Target
Actual
Comparison
Total cost of care for assigned
population compared to riskadjusted target expenditures
4
Bonus
If total expenses less than
target, portion of savings
returned to ACO
5
Distribution
ACO responsible for dividing
bonus payments among
stakeholders
Source: Health Care Advisory Board interviews and analysis.
9
Shifting from Competitors to Collaborators
Reform Accelerates Trend of Practice Acquisition by Hospitals
Physician Practice Ownership
Percentage of “Active”
Physicians Employed by Hospital
2002 - 2008
40%
100%
31%
75%
24%
22%
18%
50%
25%
5%
0%
2002
2005
Physicians
© 2011 The Advisory Board Company • www.advisory.com
2008
Hospitals
2000
15%
8%
2004
Specialists
2008
2012 (E)
PCPs
Source: Harris G, “More Doctors Giving Up Private Practices,” New York Times, March 25, 2010; Health
Care Advisory Board 2008 Survey on Physician Employment; Advisory Board interviews and analysis.
10
Robust Ambulatory Network Central to ACO Ambition
ACO Medical Management Investments
Patient
Activation
Post-Acute
Alignment
Medical Home
Infrastructure
Disease Management
Programs
Primary Care
Access
Population Health
Analytics
Electronic
Medical
Records
© 2011 The Advisory Board Company • www.advisory.com
Remote
Monitoring
Source: Advisory Board interviews and analysis.
11
The New Imperatives for Ambulatory Facility Strategy
Imperative #1
Imperative #2
Imperative #3
Expand the Front End
of the Delivery System
Rationalize Procedural
and Imaging Capacity
Reinforce the Disease
Management Enterprise
• Developing low-cost,
accessible primary care
settings
• Linking patients and
providers via virtual
clinics
• Shifting emergency care
out to satellite facilities
• Experimenting with
freestanding
observation units
• Consolidating imaging
sites to maximize asset
utilization
• Parsing out the “nice-to
have” versus “must-have”
imaging modalities
• Preparing ASCs for the
next wave of outmigration
• Creating a short-stay
surgical facility
© 2011 The Advisory Board Company • www.advisory.com
• Installing the bricks-andmortar infrastructure for
medical homes
• Developing outpatient
“one-stop shops” for the
chronically ill
• Bringing the care
continuum to the
patient’s home
• Engineering “smart
homes” for the elderly
12
Road Map for Discussion
I
II
Playing by Different Rules
Rethinking Ambulatory Facility Strategy
III Rethinking Ambulatory Facility Design
IV Migrating to a Patient-Centered Model
© 2011 The Advisory Board Company • www.advisory.com
13
Strategic Imperative #1 – Expanding Access to Primary Care
Micro-Clinics – Coming to a Storefront Near You
Kaiser Permanente Embracing New PCP Practice Model
Kaiser Permanente Micro-Clinic Core Model
On-Site Providers
2-3 providers (mix of MDs, NPs
or PAs) plus receptionist
Clinic Space
4 exam rooms, waiting room,
clean utility room
Limited Ancillary Services
No imaging, pharmacy, lab,
consult (optional add-ons)
Kaiser Permanente Micro-Clinic
• Small family practice offering 80% of services available at typical primary care office
• ~1,800 SF core model; optional add-on pharmacy, lab, basic imaging, and consult room
expand clinic up to 5,000 SF total
Note: Image courtesy of Kaiser Permanente.
© 2011 The Advisory Board Company • www.advisory.com
Source: Advisory Board interviews and analysis.
Assessing Prospects for Evolving Urgent-Emergent
Care Models
Continuum of Urgent-Emergent Care Models
Routine Primary Care
Description
Opportunities
Future
Challenges
Prospects
Emergent Care
Urgent Care
Clinic
Hybrid UrgentEmergent
Freestanding
ED
• Small primary care
practice in leased
retail space
• Service scope covers
80% of typical
primary care
• Staffed by 2-3
providers
• Standalone facility
offering walk-in,
extended hour access
for acute illness and
injury care
• Staffing varies by
location
• UCC with ED-level
diagnostic capabilities
to treat emergent
conditions
• Staffed by emergency
physicians
• Satellite full-service
emergency
department providing
full gamut of
emergency care
• Staffed by emergency
physicians
• Augment same-day,
after-hours access
• Feed referrals
• Potential to support
disease management
services
• Compressed time to
open, startup costs
• Potential to foster
better providerpatient
communication
• Recruit new patients
in underserved areas
• Offload volumes from
congested ED
• Faster, more pleasant
patient experience
• Lower cost setting
• Potential to
incorporate into
accountable care
organization strategy
• Offload volumes from
congested ED
• More efficient
throughput than ED
• Market entry strategy
• Offload volumes from
congested ED
• Expand market share
in both ED volumes
and downstream
admissions
• Improve payer mix
• Potential quality
concerns
• Service scope may be
limited
• Questionable
profitability
• Providers must weigh
benefits, drawbacks
of direct ownership
vs. partnerships
• Subscale model
• Difficult to scale up
• Certain patients will
still need to travel for
select ancillary
services
• Profitability can be
ambiguous
• Patient confusion
when selecting
appropriate care
setting
• Overcome skepticism
around patient safety
• Generate sufficient
emergent volumes to
offset additional
costs
• Overcome skepticism
around patient safety
• Competitive concerns
• Legislation spurred by
cost, overcapacity
concerns
• Robust growth
forecast as payers
cover services and
technology advances
• Strong growth
prospects in light of
PCP shortage, ACOs,
enhanced quality and
convenience
• Moderately positive
outlook primarily due
to subscale operating
costs
• Clear market need
but economics still
not attractive
• Conservative growth
outlook given safety
and cost concerns
• Healthy growth
opportunity
• Potential for
oversaturation in
some markets
Virtual Clinic
Retail Clinic
Micro-Clinic
• On-demand virtual
consultation
• Staffed by
emergency-trained
providers
• Small, walk-in clinics
located in retail
stores treat simple
illnesses, provide
preventative services
• Typically staffed by
NPs or PAs
• Augment same-day,
after-hours access
• Low capital costs
• Potential to foster
better providerpatient
communication
© 2011 The Advisory Board Company • www.advisory.com
14
Source: Advisory Board research and analysis.
15
Strategic Imperative #2 – Rationalizing Procedural Capacity
Fewer Ambulatory Surgery Centers Coming On Line
Once Dominant Surgery Centers Looking More Vulnerable
Total Number of Medicare-Certified ASCs
2002-2009
Net percent
growth from
previous year
3,512
3,814
8.6%
7.4%
4,106
4,404
4,654
5,151
4,932
5,260
New
Centers
7.7%
7.3%
5.7%
Existing
Centers
4.4%
6.0%
2.1%
305
367
2002
2003
369
2004
355
2005
332
2006
347
273
2007
2008
167
2009
Allowing Demand to Catch Up with Supply
“[W]e would expect little upside to organic growth expectations. Rather, we believe that
consolidation via M&A will be an ever-increasing avenue for growth, and new capacity growth
will have to be curtailed to allow supply/demand to become more balanced.”
Deutsche Bank
February 2008
© 2011 The Advisory Board Company • www.advisory.com
Source: MedPAC Data Book, June 2010; “Ambulatory Surgery Centers: Annual
Survey Shows Growth Continues to Slow,” Deutsche Bank, February 4, 2008.
16
Strategic Imperative #3 – Reinforce the Disease Management Enterprise
Building a Medical Home for Chronic Patients
Co-Locating Services at AtlantiCare’s Special Care Centers
Patient Profile
Services Provided
• Chronic illness such as
diabetes, heart disease,
obesity, or asthma
• Employees of union
partnering with AtlantiCare or
hospital staff
• 1,200 patients
• Plans to expand to uninsured
population
• Health coach manages
patients’ care
• PCPs serve as program leaders
• On-site specialists include
cardiology and psychiatry
• Co-located with retail
pharmacy, lab, radiology, and
after hours primary care
Case in Brief: AtlantiCare Regional Medical Center
• Nonprofit health system located in Atlantic City, New Jersey
• Special Care Centers (SCC) are patient-centered medical homes focused on chronic
diseases
• SCC is a partnership between a local union and AtlantiCare
© 2011 The Advisory Board Company • www.advisory.com
Source: Center for the Health Professions, “The Special Care Center – A Joint Venture to Address Chronic Disease,”
available at http://www.futurehealth.ucsf.edu/Content/29/201011_The_Special_Care_Center_A_Joint_Venture_to_
Address_Chronic_Disease.pdf, accessed March 28, 2011.
17
Road Map for Discussion
I
II
Playing by Different Rules
Rethinking Ambulatory Facility Strategy
III
Rethinking Ambulatory Facility Design
IV
Migrating to a Patient-Centered Model
© 2011 The Advisory Board Company • www.advisory.com
18
Improving Clinic Design from Front to Back
Three Goals of Ambulatory Facility Design
1
Streamline Front
End Operations
3
Design the Exam
Room of the Future
• Build the right size exam
room
• Facilitate high quality care
delivery through room
layout
• Ensure patient and
caregiver involvement in
care process
• Improve patient arrival
and registration
process
• Utilize technology to
speed patient visit
• Streamline patient
rooming system
2
Optimize Clinic
Design
• Encourage staff/clinician
communication through
shared workspaces
• Remove physician offices to
encourage collaboration
• Build the appropriate
number of exam rooms per
provider
© 2011 The Advisory Board Company • www.advisory.com
Source: Advisory Board interviews and analysis.
19
Kiosks Streamlining Patient Check-In
Strategic Placement and Human Support Keys to Success
Kiosk Utilization Rates
30%
Registration Staff Spaces
6
4
2
3%
Initial
1
Location
New
Location2
Without
Kiosks
With 2
Kiosks
Goal
University of Wisconsin Hospitals and Clinics, West Clinic
• Hospital-based outpatient clinic located in Madison, WI
• Installed 2 kiosks in 2007; timing aligned with migration to Epic
• Original location led patients to encounter registration staff first, new location is front
and center, eliminating lines for registration counter
1 Beyond registration counter, without framing structure
2 In front of registration counter, showcased in prominent structure
© 2011 The Advisory Board Company • www.advisory.com
Source: Advisory Board interviews and analysis.
20
Patient, Room Thyself
Self-Rooming Process Streamlines Front-End Operations
Self-Rooming Patient Flow Map
#12
Check-In
Patient checks
in at central
registration
Notify Team
Receptionist enters
patient arrival and
room assignment in
tracking system, care
team notified
Coded Card
Easy Wayfinding
Room Arrival
Patient receives
color-coded card
with room number
(or pager if no
room available)
Patient directed by
color-coded signs
to neighborhood,
then exam room
Clinician promptly
meets patient in
exam room
Park Nicollet Clinic – Chanhassen
• 56,000 SF multispecialty clinic located in Chanhassen, MN
• Opened new facility in 2005 designed around patient self-rooming , easy wayfinding, care
neighborhoods, and patient locator system
© 2011 The Advisory Board Company • www.advisory.com
Source: Advisory Board interviews and analysis.
21
Self-Rooming Significantly Downsizing Waiting Rooms
Chanhassen Clinic First Floor Plan
Waiting Area Seats per Exam Room
1.5
1
0.5
Traditional Park
Clinic
Nicollet
Optimal
Minimized waiting
room square footage
Note: Image courtesy of BWBR Architects.
© 2011 The Advisory Board Company • www.advisory.com
Source: BWBR Architects; Advisory Board interviews and analysis.
22
Improving Clinic Design from Front to Back
Three Goals of Ambulatory Facility Design
1
Streamline Front
End Operations
3
• Build the right size exam
room
• Facilitate high quality care
delivery through room
layout
• Ensure patient and
caregiver involvement in
care process
• Improve patient arrival
and registration
process
• Utilize technology to
speed patient visit
• Streamline patient
rooming system
2
Optimize Clinic
Design
• Encourage staff/clinician
communication through
shared workspaces
• Remove physician offices to
encourage collaboration
• Build the appropriate
number of exam rooms per
provider
© 2011 The Advisory Board Company • www.advisory.com
Design the Exam
Room of the Future
23
Caregivers at the Core
Facilitating Team-Based Care
A Collaborative Work Environment at St. John’s Clinic
The Care Team Module
• Five to seven physicians per module
• Upstaffed from one to two nurses per
physician
• Nurses have taken over many physician
tasks, including taking patient histories
and care coordination
• LPNs and MAs trained to advanced
competencies and work with all physicians
Case in Brief: St. John’s Clinic, Rolla
•
•
•
•
Integrated physician arm of Mercy St. John’s Health System, located in Missouri
Clinic has more than 180,000 visits per year
550 physicians, 70 offices, 40 locations
Opened redesigned clinic in 2009 with goals of improving patient experience and
efficiency and achieving a team-based care model
© 2011 The Advisory Board Company • www.advisory.com
Source: The Neenan Group, www.neenan.com; Advisory Board
interviews and analysis.
24
Caregivers Working Side-By-Side
Workstations Co-Located in Central Bullpen
Image courtesy of Anshen+Allen, a part of Stantec.
Image courtesy of St. John’s Clinic, Rolla.
Advantages of Bullpen
Enhances communication and camaraderie
among staff
Maintains sight lines to exam rooms
Reduces clinical staff footsteps, time spent
tracking down colleagues
© 2011 The Advisory Board Company • www.advisory.com
Source: Anshen+Allen, a part of Stantec; St. John’s Clinic, Rolla;
Advisory Board interviews and analysis.
25
Abolishing the Private Physician Office
Encouraging Collaboration via Shared Work Spaces at St. John’s
Behind Closed Doors
Private Physician Office
Out in the Open
Shared Staff Lounge
Touchdown Space
Physicians isolated in
individual offices
Replaced private physician offices with shared lounges
consisting of 4 work stations, book shelves, and TV;
provide “touchdown” spaces in clinic hallways
Used for dictation,
charting, meetings,
private phone calls
Accommodate physicians’ needs for privacy through
use of consult rooms, “do not enter” signs on lounge
Typically 150 SF
Reduced clinic footprint by 4,000 square feet through
elimination of private physician offices
© 2011 The Advisory Board Company • www.advisory.com
Source: Advisory Board interviews and analysis.
26
Pushing toward the New Standard
Expanded Care Team Enables Clinic to Run More Rooms
A 5 to 1 Exam Room Ratio at Mass General
Five exam rooms per
care team
Nurse practitioners
share patient panel with
physicians
Physician
Nurse Practitioner
MA escorts patient to
room and initiates visit;
nurse and case manager
provide support
Nurse
Medical
Assistant
Case
Manager
Case in Brief: Massachusetts General Hospital
•
•
•
“Ambulatory Practice of the Future” primary care clinic opened in 2010 in new
facility adjacent to main hospital
Care model relies on collaboration among multi-disciplinary care teams
Clinic is approximately 7,000 SF with 15 exam rooms
© 2011 The Advisory Board Company • www.advisory.com
Source: Advisory Board interviews and analysis.
27
A Sum Greater Than Its Parts
Leveraging the Care Team to Improve Efficiency
A Bygone Era
Today’s Standard
A Worthy Goal
5 to 1
Exam Room
to Physician
Ratio
2.5-3.0 to 1
1 to 1
 Transition to team-based
approach to care
 All clinicians working at
top of license
 Select physician tasks offloaded to LPNs and MAs
 Consolidation of practices
 Rise in patient visits due to aging
population and increase in
chronic conditions
 Primary care physician shortage
Time
© 2011 The Advisory Board Company • www.advisory.com
Source: Advisory Board interviews and analysis.
28
Improving Clinic Design from Front to Back
Three Goals of Ambulatory Facility Design
1
Streamline Front
End Operations
3
• Build the right size exam
room
• Facilitate high quality care
delivery through room
layout
• Ensure patient and
caregiver involvement in
care process
• Improve patient arrival
and registration
process
• Utilize technology to
speed patient visit
• Streamline patient
rooming system
2
Optimize Clinic
Design
• Encourage staff/clinician
communication through
shared workspaces
• Remove physician offices to
encourage collaboration
• Build the appropriate
number of exam rooms per
provider
© 2011 The Advisory Board Company • www.advisory.com
Design the Exam
Room of the Future
29
Rightsizing the Exam Room
Exam Rooms Bursting at the Seams
Team-Based, Patient-Centered Care Creating a Tight Fit
More People…
…and More Stuff
Clinicians and Caregivers
IT and Clinical Equipment
Scale to reduce patient
movement and
enhance privacy
NP/PA
PCP
RN
Social Worker
Printer to enable
in-room checkout
Wide monitor for
patient education and
information sharing
Large table for inclusive,
side-by-side interaction
Nutritionist
LPN/MA
Special equipment carts
ECHO, EKG, phlebotomy,
casting and splinting, etc.
Family
Members
Health
Coach
© 2011 The Advisory Board Company • www.advisory.com
Mobile diagnostics to
reduce patient shuffling
Source: Advisory Board interviews and analysis.
30
Finding the “Sweet Spot”
110-120 Square Feet Ideal for Universal Exam Room
Exam Room Size Assessment
<90 SF
100 SF
110–120 SF
150+ SF
“An Anachronism”
“A Tight Fit”
“The Sweet Spot”
“Unnecessary
for Most”
Inflexible; limited
“wiggle room” to
accommodate extra
care team member,
caregiver, mobile
equipment and
side-by-side consult
Currently sufficient
for most visits but
limited flexibility to
accommodate
team-based care,
electronic
information sharing
Comfortably
accommodates
three distinct zones
for provider,
patient and family,
as well as clinical
and IT equipment
© 2011 The Advisory Board Company • www.advisory.com
Financially
challenging for
most practices,
used primarily for
consult-intensive
specialties such as
oncology
Source: Advisory Board interviews and analysis.
31
Optimal Exam Room Layout
Distinct Zones Facilitate Patient-Centric Encounter
Family Zone
• Ample seating to
accommodate
caregiver(s)
• Separate from
supply zone to avoid
interference with
clinician workflow
Patient-Centric Exam Room Zones
12’
10’
Image courtesy of HKS Architects
Exam Zone
• Room must be
large enough to
allow space around
the exam table
Image courtesy of SmithGroup
© 2011 The Advisory Board Company • www.advisory.com
Supply/Hand Washing Zone
• Separate area for clinical
supply storage
Computer/Charting Zone
• Large monitor(s) mounted
on desk/wall enables equal
information sharing
• Table shape/size facilitates
exam triangle
• Moveable seating to
accommodate patient and
caregiver
• Optional in-room printer
Source: SmithGroup; HKS Architects; Advisory Board research
and analysis.
32
Exam Room Alternatives
“Talking Rooms” as Multi-Purpose, Flexible Spaces
Southcentral Foundation “Talking Rooms”
Exam room
dimensions and
location enable
ability to flex
space into
exam room
“Talking Room” Functions
• Less clinical setting for visits
that do not require exam table
• Side-by-side consults that
promote greater family
participation
• Private clinician-clinician
interactions
• Patient-clinician phone calls
• Accommodate waiting families
Southcentral Foundation, Anchorage Native Primary Care Center
• 75,000 SF outpatient facility of Alaska-native owned, nonprofit health system
• Designed to be responsive to unique needs and values of the native community
• Reflects effort to shift care to where it is most appropriately performed, reduce patient
anxiety and include extended family in care plans
Note: Floorplan courtesy of SouthCentral Foundation and NBBJ.
© 2011 The Advisory Board Company • www.advisory.com
Source: Southcentral Foundation; NBBJ; Advisory Board
interviews and analysis.
33
Group Visits Enhancing Capacity, Gaining Popularity
Consolidated Patient Encounters Maximize Provider Productivity
Clinica Campesina Thornton Clinic Floor Plan
Multiple Individual Visits
Single Group Visit
32%
Increase in provider
productivity during
group visit activity
in 20101
85%
Patients electing
to continue group
visits
Case in Brief: Clinica Campesina
• Piloted group visits in 2001 after diabetes patients no-showing for one-on-one visits but continuing
enrollment in health education class; currently 1,000 group visits annually
• Visit efficiency maximized through team-based care; PCP present for only 50-75% of group visit slot
1 4,790 patients seen in 862 group visits, individual visit slots equivalent of 3,625.
Note: Floor plan courtesy of Boulder Associates Architects.
© 2011 The Advisory Board Company • www.advisory.com
Source: Boulder Associates Architects; Advisory Board interviews and
analysis.
34
Virtual Visits Potentially Decreasing Room Demand
E-Mail and Phone Contact on the Rise
Distribution of Ambulatory Care Encounters
Kaiser Permanente Hawaii Members
4%
30%
~100%
66%
Office
Visits
Phone
Visits
E-Mail
1999
8%
Increase in
interactions
with doctor
26%
Decrease in
office visits
2007
Case in Brief: Kaiser Permanente Hawaii
• In 2004, Implemented KP HealthConnect EHR and patient portal system in outpatient setting
• By 2007, scheduled phone visits increased more than eightfold; secure online patient-provider
messaging by nearly sixfold; office visits decreased by 26%
• Care quality and patient satisfaction levels remained consistent
© 2011 The Advisory Board Company • www.advisory.com
Source: Chen C, et al, “The Kaiser Permanente Electronic Health Record:
Transforming and Streamlining Modalities Of Care,” Health Affairs, 28:2,
March/April 2009; Advisory Board interviews and analysis.
35
Road Map for Discussion
I
II
Playing by Different Rules
Rethinking Ambulatory Facility Strategy
III
Rethinking Ambulatory Facility Design
IV
Migrating to a Patient-Centered Model
© 2011 The Advisory Board Company • www.advisory.com
36
Industry Migrating to Larger Ambulatory Boxes
Average Square Footage by Facility Age
Health Care REIT Ambulatory Facilities
88,973
56,393
50,088
42,889
0-5 Years
6-10 Years
11-20 Years
20+ Years
n = 38
n = 29
n = 64
n = 26
© 2011 The Advisory Board Company • www.advisory.com
Source: Health Care REIT.
37
Putting the Patient at the Center of Facility Strategy
Hospital and Physician Concerns Dominated Previous Eras
Hospital-Centric Era
Patient-Centric Era
Physician-Centric Era
Dispersed
• Rising demand for
primary care fueling
increase of small-scale
sites
Distribution of
Ambulatory
Services
Concentrated
• OP surgery, diagnostics
delivered in the hospital
• MOB space clustered
around inpatient facilities
• Technological
innovation, shifting
incentives push care to
freestanding centers
• Physician ownership of
facilities fuels
outmigration to the
suburbs
1980
© 2011 The Advisory Board Company • www.advisory.com
• Re-aggregating OP care
to achieve economies of
scale, promote
collaboration, and offer
“one-stop shopping”
2010
Source: Advisory Board research and analysis.
38
Expanding the Portfolio at Both Ends of the Spectrum
Outpatient Facility Prototypes at Cassavetes Health1
Comprehensive
Multispecialty
Center
• 10-15 PCPs
and specialists
• Full-scale Lab
• Advanced
imaging
• Rehab
• Urgent care
• ASC
“Nurse in
a Box”
Barebones
PCP Office
MOB
Plus
• Mid-level
practitioner
• Low-acuity
urgent care
• Flu shots
• School
physicals
• 2-5 PCPs
providing
comprehensive
primary care
• Basic Lab
• Basic imaging
• 5-10 PCPs and
specialists
• Basic Lab
• Basic imaging
• Limited Rehab
Ave.
Size
Under 2,000 SF
Under 10,000 SF
10,000 - 15,000 SF
15,000 - 50,000 SF
50,000 - 100,000 SF
Ave.
Cost
$350K - $375K
Under $2.5M
$15M - $18M
$22M - $25M
$45M - $70M
Services
Offered
“Hospital
Without Beds”
• 30+ PCPs and
specialists
• Advanced imaging
• Rehab
• Urgent care
• ASC
• Oncology services
• Freestanding ED
• Observation unit
• Wellness
1 Pseudonymed 7-hospital system in the Northeast.
© 2011 The Advisory Board Company • www.advisory.com
Source: Advisory Board interviews and analysis.
Ambulatory Facility
Strategy in the Reform Era
Michael Hubble
Senior Director
The Advisory Board Company
hubblem@advisory.com
FACILITY PLANNING FORUM
© 2011 The Advisory Board Company • www.advisory.com