Eight ambulatory models of care

Photo by Veronica Weber, Palo Alto Weekly On-site, work-based clinics like this one at Facebook’s headquarters are increasingly popular with major employers, growing from 1,200 sites in 2013 to a projected 6,000 sites by 2018.

This is an interesting time in health care delivery, where the convergence of a number of major influences is spurring the development of new and blurred models of care. Nowhere is this more visible than at the ambulatory end of the spectrum.

The most obvious influence is the new financial and regulatory pressure that incentivizes 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 targeting opportunities to provide services that may complement or compete with more traditional health care providers.

Leveraging technology

If cost is a driver of the rise in ambulatory care and the proliferation of ambulatory care site types, technology is the great enabler. The use of technologies, including electronic health records, increasingly allows providers to offer multisite connected care and the promise that care will be coordinated, and redundant diagnostic tests will be reduced greatly, if not eliminated.

The other major component of technology — the smartphone and an ever-increasing number of apps and accessory devices — is in the hands of the consumer, allowing point of care and digital interaction to occur wherever and often whenever the patient-consumer desires.

Consumer preferences, particularly among younger Americans who often prefer a digital interface with health care providers, are contributing to the rise of interactions in the least acute sites.

John A. Quelch, the Charles Edward Wilson Professor of Business Administration at Harvard Business School and professor in health policy and management at 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. The preference for the precise mix of these elements differs from consumer to consumer, depending on patients’ individual needs … it probably also differs according to the situation, if it’s an emergency or it’s discretionary … I’m convinced every consumer has a different profile and a profile that varies by situation and according to the patient’s life stage.”

Although not identical to other sectors in regard to consumer expectations and preferences, health care delivery increasingly is a matter of competition in many of the same ways: convenience, speed, cost and value, especially in the ambulatory environment.

One other contributor to the proliferation of ambulatory delivery sites is the limited number of physicians, especially in primary care. One reason ambulatory care sites are less costly is that they are staffed with less-expensive personnel.

Design considerations

Ambulatory health care may be thought of as two sometimes overlapping groups: transactional care, which 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; and multidimensional care, which includes a more complex and complete review of a patient’s medical needs, such as an annual physical or infusion treatment.

There is no clear distinction between the two groups, though it can be assumed that 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, with convenience in both location and time as primary components. Retail providers treat the issue at hand and charge accordingly. Because patients are focused on single issues and are not seeking a prolonged interaction with a variety of providers, exam rooms can be small (90 net square feet).

Waiting rooms also can be small: Patients may opt to leave and do other things while waiting or simply go elsewhere if things seem too busy. From a consumer perspective, a big waiting room with lots of people waiting will be less attractive than a smaller one with fewer people waiting. Other important components of high-turnover, retail environments, such as glass fronts, easy parking, and light and inviting colors also are likely important.

Multidimensional care may require somewhat 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, and no single standard or definition is universal. Ambulatory care sites come in a variety of models, with different patients, treatment providers, provider models, key room and facility descriptions, financial characteristics and linkage requirements to a larger ambulatory network. Although there is overlap in services among the models, each has a specific market niche within the health care delivery ecosystem and serves a distinct purpose:

1. 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.

2. 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.

3. 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. Design of these sites likely will be determined by their retail setting and brand; expectations of privacy may begin to inform space utilization.

4. Urgent care. Often defined as clinics that provide general radiography, a small lab, sutures and extended hours, urgent care (UC) 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 nor operate them as efficiently as for-profit companies. For example, in 2014, Massachusetts General Hospital (MGH) 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. Design — light, bright and pleasant — and amenities, including coffee, snacks and large-screen televisions, have been identified as factors that contribute to the success of urgent care clinics. For urgent care clinics affiliated with health care systems, the UC clinic is an opportunity to extend the brand.

5. Freestanding emergency departments. Often part of health care systems that can accommodate patients who require admission, freestanding emergency departments (FEDs) 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 well change in the future. Some freestanding EDs are part of larger ambulatory care centers. As urgent care clinics cater to patients’ expectations of a pleasant interior environment, freestanding EDs may need to follow suit and distinguish themselves as attractive patient options. With a high percentage of pediatric patients, freestanding EDs have an opportunity to design for this population.

6. 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 campus 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. Work-based clinics need to manage patient concerns for privacy both from other employees and employers, and their design should complement the brand and values of the parent organization.

7. 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.

8. 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 to multiple providers on the same day. An emphasis on sub-waiting, consultation and navigable scale are important factors in the design of these centers.

Unlike pediatric specialty centers, which may have limited imaging due to issues of sedation and critical mass in all but larger cities, 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.

Awareness and satisfaction

Given the reduced cost of ambulatory environments and the speed at which change is occurring, one could expect increased experimentation with care sites that are cost-effective, and meet or exceed patient consumer expectations, and demand on clinical care delivery.

As technology allows for more sophisticated care in low-investment sites for transactional care, the spectrum of care provided may expand. However, too much upward extension may blur the transactional nature of the interaction and heighten the risk of failure to deliver on speed and convenience.

Multidimensional care sites likely will try to deliver on many of the same characteristics as transactional care, increasingly retail in regard to convenience and environment while taking on more complex outpatients for longer visits. It would not be surprising to see medical day care models expand in ambulatory settings for patients who already are receiving services but need additional assessment and treatment but not admission, and for whom going to an ED is not a cost-effective or clinically ideal option. It also may be likely that, as observational status patients continue to grow in number, there may be more ambulatory sites for their care.

This experimentation and blurring of ambulatory care models all make sense in the new world, where many more Americans have health care coverage and cost management is a priority. For some providers, just as for many retailers, the physical environment is a powerful contributor to brand awareness and customer satisfaction.

Jennifer Aliber, AIA, FACHA, is a principal at the national architecture firm of Shepley Bulfinch, where she is a leader of the firm’s health care practice. She can be reached at JAliber@shepleybulfinch.com.

Lines blur between high- and low-acuity spaces

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. Smaller, less-efficient hospitals that are part of larger systems systematically have been deactivated as acute care sites over the past several years.

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 trying to schedule 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. 

Technology allows for increased acuity off-site

As technology provides increased connectivity of patient data and information to remote sites and providers, increasingly acute patients may be treated in less-sophisticated sites.

On the least-acute end of the care spectrum, patients who once had to come in to see their clinicians for regular monitoring can do so from home using their smartphones with apps and accessories, external medical monitors that transmit patient data and implanted devices.

Telemedicine already is utilized for patient consults from either home or work to a physician or specialist and often as part of an electronic intensive care unit (eICU) model. This allows for treatment of complex patients in community hospital ICUs with an electronic connection — frequently a mobile robot as well as remote physiological monitoring. On the far end of the care spectrum, it is possible that in the future, some surgeries will be performed with surgeons who are located elsewhere.

It is likely that the general trend of technology that enables sicker and more complex patients to be seen and treated in less-acute settings will continue and may be supplemented by home visits by providers or other services coming to patients.

As ambulatory and outpatient care move out of hospitals, the question of what will be in the hospital remains. The generally shared belief that hospitals will serve relatively more acute patients is reasonable, especially given the demographics of an aging and overweight U.S. population, both of which contribute to complexity and comorbidities.

It also seems reasonable to expect that some observational status and relatively short-stay procedural patients, such as patients with knee replacements, will begin to migrate to less-acute environments.