Outpatient Care Inspires New Building Design
Snapshot
As inpatient utilization declines, outdated rural hospitals can meet their community’s changing needs by building or converting to ambulatory-driven life enhancement centers that combine health and wellness under one roof.
The shift from inpatient to outpatient care has been more dramatic in rural hospitals than in their urban counterparts. Rurals also struggle with recruiting providers and caring for an older and sicker population. If these organizations continue to operate in a fee-for-service world, they won’t survive. Disruptive changes — from value-based reimbursement to technological advances — are coming to rural health care like thunderstorms rolling across the prairie.
As rural organizations change how they function, they also may have to change how their facilities are planned and designed. To continue to renovate and build health care facilities that support an unsustainable system will add unnecessary cost and inefficiency to a system that thrives on value and positive health outcomes.
In short, rural facilities must be designed to maintain health, rather than solely treat the sick. They must be located in convenient locations and enable providers to visit patients as opposed to requiring that patients come to providers. Because payments no longer will be based on the number of office visits or services administered, physicians may need only half as many exam rooms. Additionally, providers may refer patients to former competitors if they can provide higher-quality care at lower cost. This new philosophy encompasses the meaning and purpose of health care going forward.
Changing Health Care Needs
There are approximately 1,330 critical access hospitals across the United States, and it’s unlikely that the will or resources are available to repurpose, renovate or replace every one of those organizations. However, it is smart to view planning activities and future investments through the lens of a value-based delivery model. Strategic planning for rural and community hospitals should focus on the implementation of a sustainable, value-based service model and a facility that supports it.
One option is a life enhancement center, or LEC, which is a new, renovated or repurposed facility that is designed and constructed to serve the health and wellness needs of the citizens within its service area. Because providers must deliver high-quality outcomes at the lowest cost to the system, an LEC must meet the short-term needs of consumers through collaboration with integrated practice units (a team of caregivers who focus on a chronic condition and deliver coordinated care), outpatient care and urgent care needs. At the same time, it also must support the long-term goal to improve the lives of the population served through patient-centered medical homes and wellness programs.
The physical attributes of an LEC should reflect the population’s priorities. Possible elements include:
Wellness. A wellness center can become a social magnet for patients within the service area, and it helps to define the LEC as a place that supports a healthy lifestyle. Typical wellness centers include exercise equipment, rehab providers, and physical and occupational therapists. Providers should consider approaching other public organizations, educational systems and private employers to become partners in supporting an institution that promotes healthful activities.
Nutritional services. These services create an opportunity to turn the dietary department into a communitywide resource. It can become the cornerstone of an outreach program that provides nutritional education and coaching. Identifying healthful ingredients and proper preparation methods already play an integral role in services provided by patient care coordinators and other community support organizations.
Additionally, the LEC could regularly host on its campus a farmers market that sells locally sourced meats, fruits and vegetables to the community. And by using the market as a source for its own kitchens, it could reinforce the organization’s commitment to good health.
Patient-centered medical homes. This concept has struggled in fee-for-service reimbursement systems, but it will thrive in value-based, direct care models. Because care will be provided as close to the patient as is practical, a patient-centered medical home will need fewer exam rooms. Physicians will focus on individuals who will benefit most from their attention, and coordinate the involvement of the integrated practice units. To support this workflow, the clinic could have flexible classrooms to educate the public on chronic conditions, maternal health or other topics, to hold cooking demonstrations, and to accommodate group exercise classes. The LEC also could include conference rooms for care planning teams and individual work spaces available for team members to focus on patient support services. Finally, some exam rooms could be designated as quick turnaround rooms for phlebotomy, vaccinations or observation, and others could be designed to accommodate bariatric patients.
Emergency, urgent care and nursing services. LECs should have, with rare exceptions, emergency services capable of handling all but the most intense trauma conditions. The low volume and limited access to specialists in remote locations demand a creative solution, so a high-speed connection to a teletrauma services provider associated with a regional trauma center will be essential. Nursing services and patient observation are part of the areas of staff responsibility of this combined department. The number of observation beds depends on the program requirements. Inpatient beds may or may not be needed in an LEC.
Clinical services. Traditional silos of clinical services are integrated into a single, customer-focused diagnostic and treatment center. The range and variety of clinical services depends on several factors, including geographical location, community demographics, patient volume and arrangements with other area wellness districts. In general, though, a customer-focused outpatient center, arranged so that services are accessible from a single reception point, will improve the patient experience. Home and mobile health monitoring systems can assist the staff in meeting each visitor’s specific needs and expectations. The goal should be seamless visits with no wait time. Depending on the codes and regulations for the facility, clinical services may include:
• urgent care and recovery
• ambulatory surgery
• medical imaging, including ultrasound, MRI, CT and X-ray
• infusion therapy
• sleep medicine
• endoscopy
• telemedicine capabilities for remote consults
• laboratory
• respiratory therapy
• diagnostic cardiology
• phlebotomy
• pulmonary function testing
The LEC’s clinical services must be provided in the most cost-effective manner possible. It must leverage services that it can provide better than other organizations, improve services that are marginal and be willing to forgo those that don’t fit this model. A highly capable, cross-trained staff, already common in rural and community health centers, is needed here, too.
Administrative services and retail operations. Administrative and business functions can be consolidated in an LEC. In a fully capitated environment, there will be fewer business office functions. Nevertheless, administrative and business staff, information technology experts and human resources staff still will be needed. Retail operations could include optometry, durable medical equipment, pharmacy, dentistry, and health and fitness equipment.
Finally, an LEC should be an open, sunlit space in which wayfinding is intuitive. The frame should consist of large structural bays with widely spaced support columns and without bearing walls so the space can be reconfigured as needs change. Locating the superstructure high overhead allows an intervening space to be built above the ceilings of the occupied spaces to contain mechanical, electrical and communication systems. This also builds in flexibility so that occupied spaces below can be modified or reconfigured easily and inexpensively.
Linking Providers to Data
Electronic patient data will continue to play a growing role in monitoring consumers’ and patients’ activities and lifestyles. The LEC could become the coordinator of health-related data and communications for all providers in a so-called “wellness district.” Cloud-based systems can provide the ability to share data across multiple platforms from any location with Internet access or with smartphone coverage. Access to mobile physicians or nonphysician providers for consultation in a dynamic dance of collaborative care reduces the need for costly infrastructure investments and allows for greater flexibility to adjust to new technologies.
As wondrous as technology is, it is of little value without human interaction. A patient who has diminished capacity or who may have fallen behind the technology curve will derive little value from a monitoring device or communication tool that he or she does not understand. In these cases, having a mobile care provider come to the home and interact with the patient will pay dividends. With a mobile care provider maintaining routine personal monitoring, the primary care physician will be able to devote more of his or her time to a reduced number of more acute clinic visits.
Building a Sustainable Model
The shift from fee-for-service to value-based care pushes providers into a merit-based business model. As a result, providers will need to weigh and mitigate risk and formulate strategies to increase margins by optimizing performance. A capital investment in infrastructure that will improve operational and clinical efficiency can have a positive impact on patient outcomes and on the system’s bottom line.
In a fast-moving, ever-changing health care environment, asset liquidity is important. Partnering with an investor or lender who has experience in recognizing and leveraging risk vs. potential reward may be an intelligent decision. Public-private partnerships can be structured to provide a design, build and leaseback arrangement with the operating costs of the facility built into the contract. When a hospital that has become a shrine for a system that is no longer viable, repurposing it or replacing it with an LEC is an investment in a brighter future.
Form ever follows function, but function is determined by the synthesis of cultural, financial, political and technological goals. Consumers want a health care system that is responsive to their needs and accountable for their care. An LEC’s form may be as diverse and unique as the population it serves. It also may evolve, expand or contract as community needs and the ways of meeting those needs change.
The LEC can become the center of rural community social activity and the focal point of healthy lifestyles. A system that is self-supporting and achieves a symbiotic relationship with the community it serves will be sustainable well into the future.
Douglas Elting, AIA, ACHA, EDAC (doug.elting@viarchitecture.com), is managing principal, Visions in Architecture, Lincoln, Neb.