The convergence of a number of major influences on health care is spurring the development of new and blurred models of care. Nowhere is this more visible than at the ambulatory end of the spectrum.
New financial and regulatory pressures incentivize both providers and insurers to deliver care in the less costly and more efficient ambulatory environment, often as part of a larger health care system or network.
For-profit companies also are looking for opportunities to complement or compete with more traditional health care providers.
The great enabler: technology
If cost is driving the rise in ambulatory care, technology is the great enabler. The use of technologies, including electronic health records, increasingly allows providers to offer care connected across multiple sites and the promise that it will be coordinated — reducing, if not eliminating, redundant diagnostic tests.
The other major component of technology — the smartphone and an ever-increasing number of apps and accessory devices — allows point of care and digital interaction to occur wherever and often whenever the patient-consumer desires. Younger consumers in particular often prefer a digital interface with health care providers.
John A. Quelch, a professor at Harvard Business School and the Harvard T.H. Chan School of Public Health, recently wrote of the five E’s of patient consumer concerns: expertise, empathy, efficiency, economy and empowerment. How those elements interrelate varies from one consumer to another based on preference and situation — for instance, how urgent the health issue is.
Although health care delivery differs from other sectors in regard to consumer expectations and preferences, providers are starting to compete in many of the same ways: on convenience, speed, cost and value.
Another factor in the growth of ambulatory sites is the limited number of physicians, especially in primary care. Ambulatory care sites are less costly in part because they are staffed with less-expensive personnel.
Ambulatory health care may be thought of as two sometimes overlapping groups. Transactional care has a single, primary focus, such as a vaccination, a camp physical or even the determination of a fracture, and is likely to be viewed by the patient as low anxiety. Multidimensional care, on the other hand, includes a more complex and complete review of a patient’s medical needs, such as an annual physical or infusion treatment.
Transactional encounters are largely urgent and unplanned. They also may be less dependent on the presence of a physician to provide care. The design requirements of transactional and multidimensional care delivery also are different.
Transactional care likely reflects a retail environment and character; convenience in both location and time are primary components. Because patients are focused on single issues and are not seeking a prolonged interaction with a variety of providers, exam rooms can be small.
Waiting rooms also can be small: Patients may opt to leave and do other things before seeing a clinician or simply go elsewhere if things seem too busy. From a consumer perspective, a big room with lots of people waiting is less attractive than a smaller one with fewer people. Easy parking, light and inviting colors and glass fronts are important considerations.
Multidimensional care may require larger rooms. Patients may have family with them and may be seeing more than one provider in the exam room. The patients’ ability to review lab data and other information with clinicians requires that the exam room include a large monitor and a place for consultative discussion.
State requirements vary in terms of space requirements and on-site physician presence, so there’s no single standard or definition. Ambulatory care sites come in a variety of models. Although there is overlap, each has a specific market niche within the health care ecosystem and serves a distinct purpose:
- Smartphones, computers and the Internet. The most prevalent care site is the Internet, whether patients are in touch with their care providers through portals or medical websites. New apps and smartphone accessories likely will increase health care providers’ ability to monitor, assess and care for patients in their homes and offices. Consistency of the patient experience across physical and digital platforms is both a significant challenge and a design opportunity for providers.
- Mobile care. Historically, mobile care has consisted of converted buses used as part of charitable outreach programs for patients who otherwise would not have access to care. New models of mobile care are beginning to arise and compete on the basis of convenience. Driverless vehicles also may provide care environments that come to patients, equipped with technologies beyond those available at home or office, even if they don’t come with a care provider. Design may be a factor in acceptance, especially among younger patient consumers.
- Convenient care and retail clinics. Typically located in existing retail drug and big-box stores, these clinics treat a limited number of conditions and are staffed by mid-level providers on a first-come, first-seen basis, though there is some experimentation with scheduled appointments. The costs of services typically are posted and make it simpler for consumers to understand their obligations. Ease of parking, long weekday and weekend hours and one-stop shopping for over-the-counter items make these sites appealing for many patients and explain their exponential growth from 1,200 sites in 2013 to 6,000 projected by 2018.
- Urgent care. Often defined as clinics that provide general radiography, a small lab, sutures and extended hours, urgent care clinics now exist as both part of larger health care systems and for-profit companies. They are likely to be increasingly connected to both as health care systems realize that they may not be able to provide the desired number of sites or operate them as efficiently as for-profit companies. For example, in 2014, Massachusetts General Hospital announced an affiliation with MedSpring Urgent Care, with physicians at these sites who would be fully MGH-accredited. Services may include scheduled as well as unscheduled visits, with extended hours and physicians in attendance in addition to physician assistants and other mid-level medical staff. For health care systems, the urgent care clinic is an opportunity to extend the brand.
- Freestanding emergency departments. Often part of health care systems that can accommodate patients who require admission, freestanding emergency departments provide services that fall between those of urgent care clinics and hospital-based EDs. Open 24/7, freestanding EDs typically do not include the full range of imaging modalities, lab capabilities or observation beds, though this may change. Some freestanding EDs are part of larger ambulatory care centers.
- Work-based clinics. The long history of work-based clinics, which began in the 1860s, has gained traction over the past decade as a way to keep employees healthier and more productive. It’s not just manufacturing companies that see the value in work-based clinics; Silicon Valley employers understand that many of their employees don’t want to bother leaving the company grounds for care. As recent college graduates, many may treat this as an extension of campus health care. Thirty-seven percent of organizations with 5,000 or more employees have work-based clinics, with a workforce of approximately 1,500 considered the minimum for cost-effectiveness.
- Primary care clinics. Growing in size and displacing the single or paired primary care physician model, primary care clinics now focus on team care that may include more collaborative spaces to support medical homes and group visits. As primary care becomes folded into larger systems, some specialists (e.g., endocrinologists, cardiologists) may be part of the teams to provide more comprehensive care, and limited diagnostics may be required on-site. Exam rooms increasingly are designed for a consultative model of care in which the patient may stay sitting up and dressed, with access to a video screen for a telemedicine conference with a specialist in a remote location.
- Specialty care and high-tech centers. Pediatric and adult models of specialty care may be different in regard to size and imaging capability. A significant number of pediatric patients have weekly or monthly visits as well as appointments with multiple providers on the same day.
Unlike pediatric specialty centers, which may have limited imaging in all but larger cities due to issues of sedation and critical mass, adult specialty centers are often billed as “hospitals without beds,” and may combine sizable surgical suites, comprehensive ambulatory cancer care and a full range of imaging modalities. Design elements increasingly follow the retail models of creating spaces and events where people want to spend time, such as farmers markets, gardens, courtyards and other places that aren’t traditional waiting rooms or lobbies.
Jennifer Aliber, is a principal at the national architecture firm of Shepley Bulfinch, where she is a leader of the firm’s health care practice.
The lines between high- and low-acuity spaces are blurring. Here are some of the main points that board members should keep in mind:
- As part of their effort to deliver the right care in the right place at the right time, hospitals and health care systems are extending their reach to less-acute care sites, which have been and likely will continue to multiply in the future.
- The number of hospitals and acute care hospital beds, on the other hand, is not expected to grow dramatically, though there will need to be considerable capital investment to replace aging and inefficient facilities.
- Some of the less-acute care sites, including retail and convenience clinics, are experimenting with what might be considered “upstream” services and providing primary care — just as primary care groups are increasingly adding specialists for more acute and complex patients.
- Each end of the spectrum is working toward the other, trying to cover all patients and markets, both for patient health and wellness as well as keeping patients out of more expensive care sites, capturing revenue that might otherwise go elsewhere.
- As part of this move to the middle, care providers that have focused on on-demand, walk-in services, such as retail and convenience clinics and freestanding emergency departments, are scheduling some services. Likewise, larger primary and specialty care practices that had offered only scheduled appointments are working to provide same-day and walk-in access to patients.
- Large ambulatory care and specialty care centers, especially “hospitals without beds,” may continue to push toward more complex patients and develop ways of treating overnight to multiday stays, if regulatory agencies allow.