Facility Planning Forum

Facility Planning Forum
Ambulatory Facility Strategy in the Reform Era Michael Hubble Senior Director The Advisory Board Company Facility Planning Forum

Playing by Different Rules
Rethinking Ambulatory Facility Strategy Rethinking Ambulatory Facility Design Migrating to a Patient-Centered Model

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 Inpatient Blunting competition from physician-owned facilities Creating new feeders for the inpatient enterprise Both Building a platform for a future inpatient facility 80% of hospitals were planning outpatient expansion Source: Bank of America, “Health Care Facilities,” Equities Research, July 2007: Advisory Board interviews and analysis.

Major Reform Milestones
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 CMS releases proposed rule for Medicare Shared Savings Program HHS releases Medicare Value-Based Purchasing Program final rule VA Attorney General files first lawsuit against individual mandate President Obama repeals 1099 reporting requirement from PPACA CMS issues provisions to Hospital Readmissions Reduction Program Source: Health Care Advisory Board interviews and analysis.

Cumulative Increase in Insured Massachusetts Residents
Health Insurance Reform Virtually Eliminating the Uninsured Massachusetts Universal Coverage Initiative Cumulative Increase in Insured Massachusetts Residents Massachusetts Coverage Expansion Thousands 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 87% of coverage expansion achieved by January 2008, one year after exchange became available Source: Division of Health Care Finance and Policy, “Health Care Indicators in Massachusetts,” November 2009; Health Care Advisory Board interviews and analysis.

Utilization of Specific Services, Massachusetts Adults
Preventive Care Utilization Has Increased… Utilization of Specific Services, Massachusetts Adults Based on Self-Reported Data, n = 13,150 Percent Change in Utilization Preventive Care 9.6% Took Any Drug Specialist Visit Preventive Care 4.1% ED Visit Took Any Drug 5.5% Specialist Visit (0.5%) ED Visit Source: Long S and Stockley K, “Sustaining Health Reform in a Recession: An Update on Massachusetts as of Fall 2009,” Health Affairs, June : ; Health Care Advisory Board interviews and analysis.

Hospital-Physician Bundling
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-for- Performance Care Continuum Source: Health Care Advisory Board interviews and analysis.

Shared Savings Payment Cycle
Biggest News of the Year? Medicare Shared Savings Program Holding Providers Accountable Shared Savings Payment Cycle Program in Brief: Medicare Shared Savings Program Assignment Patients assigned to ACO based on terms of contract 1 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 Billing Providers bill normally, receive standard fee-for-service payments 2 Comparison Total cost of care for assigned population compared to risk-adjusted target expenditures 3 Bonus If total expenses less than target, portion of savings returned to ACO 4 Distribution ACO responsible for dividing bonus payments among stakeholders 5 Source: Health Care Advisory Board interviews and analysis.

Shifting from Competitors to Collaborators
Reform Accelerates Trend of Practice Acquisition by Hospitals Physician Practice Ownership Percentage of “Active” Physicians Employed by Hospital 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.

ACO Medical Management Investments
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 Remote Monitoring Source: Advisory Board interviews and analysis.

The New Imperatives for Ambulatory Facility Strategy
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 Installing the bricks-and-mortar 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

Kaiser Permanente Micro-Clinic Core Model
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. Source: Advisory Board interviews and analysis.

Continuum of Urgent-Emergent Care Models Hybrid Urgent-Emergent
Assessing Prospects for Evolving Urgent-Emergent Care Models Continuum of Urgent-Emergent Care Models Routine Primary Care Emergent Care Virtual Clinic Retail Clinic Micro-Clinic Urgent Care Clinic Hybrid Urgent-Emergent Freestanding ED Description 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 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 Opportunities Augment same-day, after-hours access Low capital costs Potential to foster better provider-patient communication Feed referrals Potential to support disease management services Compressed time to open, startup costs 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 More efficient throughput than ED Market entry strategy Expand market share in both ED volumes and downstream admissions Improve payer mix Challenges 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 Competitive concerns Legislation spurred by cost, overcapacity concerns Future Prospects 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 Source: Advisory Board research and analysis.

Total Number of Medicare-Certified ASCs
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 Net percent growth from previous year New Centers 8.6% Existing Centers 7.4% 7.7% 7.3% 4.4% 5.7% 6.0% 2.1% 167 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 Source: MedPAC Data Book, June 2010; “Ambulatory Surgery Centers: Annual Survey Shows Growth Continues to Slow,” Deutsche Bank, February 4, 2008.

Building a Medical Home for Chronic Patients
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 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 Services Provided 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 Source: Center for the Health Professions, “The Special Care Center – A Joint Venture to Address Chronic Disease,” available at Address_Chronic_Disease.pdf, accessed March 28, 2011.

Streamline Front End Operations
Improving Clinic Design from Front to Back Three Goals of Ambulatory Facility Design Improve patient arrival and registration process Utilize technology to speed patient visit Streamline patient rooming system Streamline Front End Operations Design the Exam Room of the Future 1 3 Build the right size exam room Facilitate high quality care delivery through room layout Ensure patient and caregiver involvement in care process Encourage staff/clinician communication through shared workspaces Remove physician offices to encourage collaboration Build the appropriate number of exam rooms per provider 2 Optimize Clinic Design Source: Advisory Board interviews and analysis.

Kiosk Utilization Rates Registration Staff Spaces
Kiosks Streamlining Patient Check-In Strategic Placement and Human Support Keys to Success Kiosk Utilization Rates Registration Staff Spaces 1 2 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 Beyond registration counter, without framing structure In front of registration counter, showcased in prominent structure Source: Advisory Board interviews and analysis. Here’s a case study of the University of Wisconsin, West Clinic, which, after a bit of trial and error, have deployed kiosks to successfully empower patients to perform their own check-in, thereby reducing the workload for their registration staff. Two key lessons learned here: placement of these kiosks must be very prominent. They initial location was such that patients walked by the registration desk first and queued up there without noticing the self-service kiosks. The second lesson, situating a human facilitator near the machines to encourage and support kiosk use drastically improved utilization rates as well. In fact, at peak times when there used to be lines for the registration desk, there are now sometimes lines to use the kiosks. On the right, the reduction in space needed for registration FTEs enabled by kiosks. Transition: Administrators are aiming to add a third kiosk and ramp up capabilities from basic check-in, co-pay, and wayfinding to patient portal access and clinical questionnaires.

Self-Rooming Patient Flow Map
Patient, Room Thyself Self-Rooming Process Streamlines Front-End Operations Self-Rooming Patient Flow Map #12 Check-In Notify Team Coded Card Easy Wayfinding Room Arrival Patient checks in at central registration Receptionist enters patient arrival and room assignment in tracking system, care team notified 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 Source: Advisory Board interviews and analysis. This is the story of Park Nicollet Clinic, Chanhassen, which has embraced the self-service trend and empowered patients to self-guide to their assigned exam rooms using color-coded cards and clear clinic signage. Of course, this isn’t as easy at it looks. Park Nicollet has a back-end online tracking system viewable by all nurses and front desk staff with a comment section used for communication. The tracker cell for time turns blue to alert staff if a patient has been waiting for ten minutes. A permutation on this: other facilities we spoke with had implemented Vocera technology to alert staff that a patient was ready and waiting for the next stage of their visit. To allay any concerns you might have about patients getting lost or frustrated, a physiatrist at Pacific Medical, another organization that implemented self-rooming said, he “…had an 82-year-old man with dementia and ataxia who was able to find his room just fine. So, I guess we’ll be OK!” Transition: As you might imagine, self-rooming drastically reduces time spent waiting and therefore can impact waiting room size.

Chanhassen Clinic First Floor Plan Waiting Area Seats per Exam Room
Self-Rooming Significantly Downsizing Waiting Rooms Chanhassen Clinic First Floor Plan Waiting Area Seats per Exam Room 1.5 1 Minimized waiting room square footage Note: Image courtesy of BWBR Architects. Source: BWBR Architects; Advisory Board interviews and analysis. Shown on the left here is the ground floor of Park Nicollet, Chanhassen, highlighting its relatively small waiting room. And on the right some data demonstrating the reduction in waiting room seating thanks to the success of self-rooming. Clinic administrators noted that while they cut their waiting room sizes, the remaining space is actually under-utilized and they could have cut even more space. By designing the clinic with a smaller waiting area and narrower hallways, Pacific Medical Center, which also practices self rooming, could accommodate more exam rooms and services, like an onsite endoscopy suite. Transition: The other key benefit embedded in self-rooming is obviously a reduction in waiting time. And in case you’re thinking, well, isn’t the wait just transferred from the waiting room to the exam room, on this next slide is the story of Virginia Mason’s Kirkland Clinic.

Streamline Front End Operations Optimize Clinic Design
Improving Clinic Design from Front to Back Three Goals of Ambulatory Facility Design Improve patient arrival and registration process Utilize technology to speed patient visit Streamline patient rooming system Streamline Front End Operations Design the Exam Room of the Future 1 3 Build the right size exam room Facilitate high quality care delivery through room layout Ensure patient and caregiver involvement in care process Encourage staff/clinician communication through shared workspaces Remove physician offices to encourage collaboration Build the appropriate number of exam rooms per provider Optimize Clinic Design 2

Facilitating Team-Based Care
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 Source: The Neenan Group, Advisory Board interviews and analysis.

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 Source: Anshen+Allen, a part of Stantec; St. John’s Clinic, Rolla; Advisory Board interviews and analysis.

Private Physician Office
Abolishing the Private Physician Office Encouraging Collaboration via Shared Work Spaces at St. John’s Behind Closed Doors Out in the Open Private Physician Office Shared Staff Lounge Touchdown Space Physicians isolated in individual offices Used for dictation, charting, meetings, private phone calls Typically 150 SF Replaced private physician offices with shared lounges consisting of 4 work stations, book shelves, and TV; provide “touchdown” spaces in clinic hallways Accommodate physicians’ needs for privacy through use of consult rooms, “do not enter” signs on lounge Reduced clinic footprint by 4,000 square feet through elimination of private physician offices Source: Advisory Board interviews and analysis.

A 5 to 1 Exam Room Ratio at Mass General
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 Nurse Practitioner Physician 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 Source: Advisory Board interviews and analysis.

Exam Room to Physician Ratio
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 Transition to team-based approach to care All clinicians working at top of license Select physician tasks off-loaded to LPNs and MAs Exam Room to Physician Ratio to 1 1 to 1 Consolidation of practices Rise in patient visits due to aging population and increase in chronic conditions Primary care physician shortage Time Source: Advisory Board interviews and analysis.

Streamline Front End Operations Optimize Clinic Design
Improving Clinic Design from Front to Back Three Goals of Ambulatory Facility Design Improve patient arrival and registration process Utilize technology to speed patient visit Streamline patient rooming system Streamline Front End Operations Design the Exam Room of the Future 1 3 Build the right size exam room Facilitate high quality care delivery through room layout Ensure patient and caregiver involvement in care process Encourage staff/clinician communication through shared workspaces Remove physician offices to encourage collaboration Build the appropriate number of exam rooms per provider Optimize Clinic Design 2

Exam Rooms Bursting at the Seams
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 Printer to enable in-room checkout Wide monitor for patient education and information sharing RN Social Worker 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 Mobile diagnostics to reduce patient shuffling Source: Advisory Board interviews and analysis. The expansion of the care team and inclusion of family members in patients’ care are placing capacity constraints on the typical exam room. In addition, the push toward patient-centric care has prompted a trend to house more equipment within each room. For example, if you perform self-rooming or want to improve patient privacy, each room must have its own scale. Some institutions are also “uptraining” their MAs to be present in the room throughout the visit (University of Utah) and perform in-room checkout through the scheduling system, which requires a printer stationed within each exam room as well. Transition: With all of these individuals and items crowding in, exactly how large should the universal exam room be?

Exam Room Size Assessment
Finding the “Sweet Spot” Square Feet Ideal for Universal Exam Room Exam Room Size Assessment <90 SF “An Anachronism” Inflexible; limited “wiggle room” to accommodate extra care team member, caregiver, mobile equipment and side-by-side consult 100 SF “A Tight Fit” Currently sufficient for most visits but limited flexibility to accommodate team-based care, electronic information sharing 110–120 SF “The Sweet Spot” Comfortably accommodates three distinct zones for provider, patient and family, as well as clinical and IT equipment 150+ SF “Unnecessary for Most” Financially challenging for most practices, used primarily for consult-intensive specialties such as oncology Source: Advisory Board interviews and analysis.

Distinct Zones Facilitate Patient-Centric Encounter
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’ Image courtesy of HKS Architects 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 10’ Exam Zone Room must be large enough to allow space around the exam table Image courtesy of SmithGroup Supply/Hand Washing Zone Separate area for clinical supply storage Source: SmithGroup; HKS Architects; Advisory Board research and analysis. 110’-120’ SF for universal exam room Consult performed in the room Avoid physician having back to patient. Computer zone shown here is a shot from the Ambulatory Practice of the Future at MGH, where the physician pulls up the EMR on one screen and other images or test results on the other Certain specialties can use same size room and maintain separate zones but require specific equipment (ENT, Opth, Ortho)

Southcentral Foundation “Talking Rooms” “Talking Room” Functions
Exam Room Alternatives “Talking Rooms” as Multi-Purpose, Flexible Spaces Southcentral Foundation “Talking Rooms” “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 Exam room dimensions and location enable ability to flex space into exam room 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. Source: Southcentral Foundation; NBBJ; Advisory Board interviews and analysis.

32% 85% Group Visits Enhancing Capacity, Gaining Popularity
Consolidated Patient Encounters Maximize Provider Productivity Clinica Campesina Thornton Clinic Floor Plan 32% Multiple Individual Visits Increase in provider productivity during group visit activity in 20101 Single Group Visit 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 4,790 patients seen in 862 group visits, individual visit slots equivalent of 3,625. Note: Floor plan courtesy of Boulder Associates Architects. Source: Boulder Associates Architects; Advisory Board interviews and analysis. There are two group visit rooms on the left hand side of the floor plan with connected individual exam rooms if they are needed for patients who need privacy for an exam. There is also an adjacent bathroom and mini-labs for doing INRs for the anticoag group or HbA1cs for the diabetics. Each group visit room accommodates up to 25 patients. Patient Satisfaction:Answers to questions patients might not have thought of, group learning for lifestyle changes, social time, patient support; Strengthens relationship with practice and care team Staff Satisfaction: Reduces repetition of basic diabetes education information; Better patient engagement Demonstrated care quality improvement in certain patient populations 3 exam rooms per provider Can vary size of group room depending on number of patients. Ambulatory Practice of the Future has flexible walls in their conference room.

Distribution of Ambulatory Care Encounters
Virtual Visits Potentially Decreasing Room Demand and Phone Contact on the Rise Distribution of Ambulatory Care Encounters 8% Kaiser Permanente Hawaii Members Increase in interactions with doctor 4% Office Visits ~100% 26% Phone Visits Decrease in office visits 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 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.

Average Square Footage by Facility Age
Industry Migrating to Larger Ambulatory Boxes Average Square Footage by Facility Age Health Care REIT Ambulatory Facilities n = 38 n = 29 n = 64 n = 26 Source: Health Care REIT.

Physician-Centric Era Distribution of Ambulatory Services
Putting the Patient at the Center of Facility Strategy Hospital and Physician Concerns Dominated Previous Eras Hospital-Centric Era Physician-Centric Era Patient-Centric Era Dispersed Rising demand for primary care fueling increase of small-scale sites Distribution of Ambulatory Services Technological innovation, shifting incentives push care to freestanding centers Physician ownership of facilities fuels outmigration to the suburbs Re-aggregating OP care to achieve economies of scale, promote collaboration, and offer “one-stop shopping” OP surgery, diagnostics delivered in the hospital MOB space clustered around inpatient facilities Concentrated 1980 2010 Source: Advisory Board research and analysis.

Expanding the Portfolio at Both Ends of the Spectrum
Outpatient Facility Prototypes at Cassavetes Health1 Comprehensive Multispecialty Center “Nurse in a Box” Barebones PCP Office MOB Plus “Hospital Without Beds” 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 10-15 PCPs and specialists Full-scale Lab Advanced imaging Rehab Urgent care ASC 30+ PCPs and specialists Advanced imaging Rehab Urgent care ASC Oncology services Freestanding ED Observation unit Wellness Services Offered Ave. Size Under 2,000 SF Under 10,000 SF 10, ,000 SF 15, ,000 SF 50, ,000 SF Ave. Cost $350K - $375K Under $2.5M $15M - $18M $22M - $25M $45M - $70M 1 Pseudonymed 7-hospital system in the Northeast. Source: Advisory Board interviews and analysis.

Facility Planning Forum
Ambulatory Facility Strategy in the Reform Era Michael Hubble Senior Director The Advisory Board Company Facility Planning Forum

Facility Planning Forum

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