Presentation on theme: "Facility Planning Forum"— Presentation transcript:
1 Facility Planning Forum Ambulatory Facility Strategy in the Reform EraMichael HubbleSenior DirectorThe Advisory Board CompanyFacility Planning Forum
2 Playing by Different Rules Rethinking Ambulatory Facility StrategyRethinking Ambulatory Facility DesignMigrating to a Patient-Centered Model
3 Hospital Outpatient Strategy circa 2007 Health Systems Placing Big Bets on Ambulatory ExpansionPlanned Hospital Expansions Within Next Two YearsPrincipal Drivers of Outpatient Investmentn=199Capturing profitable outpatient business in new marketsNeitherOutpatientInpatientBlunting competition from physician-owned facilitiesCreating new feeders for the inpatient enterpriseBothBuilding a platform for a future inpatient facility80% of hospitals were planning outpatient expansionSource: Bank of America, “Health Care Facilities,” Equities Research, July 2007: Advisory Board interviews and analysis.
4 Major Reform Milestones Hard to Believe It Was Just 2 Years Ago…From Health Care Reform to Payment ReformMajor Reform MilestonesPatient Protection and Affordable Care Act (PPACA) passes House of RepresentativesHHS releases Meaningful Use regulationsCMS releases proposed rule for Medicare Shared Savings ProgramHHS releases Medicare Value-Based Purchasing Program final ruleVA Attorney General files first lawsuit against individual mandatePresident Obama repeals 1099 reporting requirement from PPACACMS issues provisions to Hospital Readmissions Reduction ProgramSource: Health Care Advisory Board interviews and analysis.
5 Cumulative Increase in Insured Massachusetts Residents Health Insurance ReformVirtually Eliminating the UninsuredMassachusetts Universal Coverage InitiativeCumulative Increase in Insured Massachusetts ResidentsMassachusetts Coverage ExpansionThousandsImplemented July 1, 2006; reduced uninsured rate to 2.6%Individual and employer mandates establishedIndividual penalty initially set at $219 with monthly incremental increasesEmployer penalty at $295 annually per employeeIndividual and small group markets merged, managed through online “exchange”New publicly managed insurance options createdCharity care funds reallocated from disproportionate share payments to coverage subsidies87% of coverage expansion achieved by January 2008, one year after exchange became availableSource: Division of Health Care Finance and Policy, “Health Care Indicators in Massachusetts,” November 2009; Health Care Advisory Board interviews and analysis.
6 Utilization of Specific Services, Massachusetts Adults Preventive Care Utilization Has Increased…Utilization of Specific Services, Massachusetts AdultsBased on Self-Reported Data,n = 13,150Percent Change in UtilizationPreventive Care9.6%Took Any DrugSpecialist VisitPreventive Care4.1%ED VisitTook Any Drug5.5%Specialist Visit(0.5%)ED VisitSource: 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.
7 Hospital-Physician Bundling Payment ReformToward Accountable CareBuilding Accountability through Experiments in PaymentCapitation/Shared-Savings ModelsEpisodic BundlingDegree of Shared RiskHospital-Physician BundlingPay-for-PerformanceCare ContinuumSource: Health Care Advisory Board interviews and analysis.
8 Shared Savings Payment Cycle Biggest News of the Year?Medicare Shared Savings Program Holding Providers AccountableShared Savings Payment CycleProgram in Brief: Medicare Shared Savings ProgramAssignmentPatients assigned to ACO based on terms of contract1Program begins January 1, 2012; contracts to last minimum of three yearsPhysician groups and hospitals eligible to participate, but primary care physicians must be included in any ACO groupParticipating ACOs must serve at least 5,000 Medicare beneficiariesBonus potential to depend on Medicare cost savings, quality metricsTwo options available: one with no downside risk until year three, the second with downside risk in all three yearsProposed rule available for comment until end of May; final rule due later this yearBillingProviders bill normally, receive standard fee-for-service payments2ComparisonTotal cost of care for assigned population compared to risk-adjusted target expenditures3BonusIf total expenses less than target, portion of savings returned to ACO4DistributionACO responsible for dividing bonus payments among stakeholders5Source: Health Care Advisory Board interviews and analysis.
9 Shifting from Competitors to Collaborators Reform Accelerates Trend of Practice Acquisition by HospitalsPhysician Practice OwnershipPercentage of “Active” Physicians Employed by HospitalSource: 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 ACO Medical Management Investments Robust Ambulatory Network Central to ACO AmbitionACO Medical Management InvestmentsPatient ActivationPost-Acute AlignmentMedical Home InfrastructureDisease Management ProgramsPrimary Care AccessPopulation Health AnalyticsElectronic Medical RecordsRemote MonitoringSource: Advisory Board interviews and analysis.
11 The New Imperatives for Ambulatory Facility Strategy Expand the Front End of the Delivery SystemRationalize Proceduraland Imaging CapacityReinforce the Disease Management EnterpriseDeveloping low-cost, accessible primary care settingsLinking patients and providers via virtual clinicsShifting emergency care out to satellite facilitiesExperimenting with freestanding observation unitsConsolidating imaging sites to maximize asset utilizationParsing out the “nice-to have” versus “must-have” imaging modalitiesPreparing ASCs for the next wave of outmigrationCreating a short-stay surgical facilityInstalling the bricks-and-mortar infrastructure for medical homesDeveloping outpatient “one-stop shops” for the chronically illBringing the care continuum to the patient’s homeEngineering “smart homes” for the elderly
12 Playing by Different Rules Rethinking Ambulatory Facility StrategyRethinking Ambulatory Facility DesignMigrating to a Patient-Centered Model
13 Kaiser Permanente Micro-Clinic Core Model Strategic Imperative #1 – Expanding Access to Primary CareMicro-Clinics – Coming to a Storefront Near YouKaiser Permanente Embracing New PCP Practice ModelKaiser Permanente Micro-Clinic Core ModelOn-Site Providers2-3 providers (mix of MDs, NPs or PAs) plus receptionistClinic Space4 exam rooms, waiting room, clean utility roomLimited Ancillary ServicesNo imaging, pharmacy, lab, consult (optional add-ons)Kaiser Permanente Micro-ClinicSmall 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 totalNote: Image courtesy of Kaiser Permanente.Source: Advisory Board interviews and analysis.
14 Continuum of Urgent-Emergent Care Models Hybrid Urgent-Emergent Assessing Prospects for Evolving Urgent-Emergent Care ModelsContinuum of Urgent-Emergent Care ModelsRoutine Primary CareEmergent CareVirtual ClinicRetail ClinicMicro-ClinicUrgent Care ClinicHybrid Urgent-EmergentFreestanding EDDescriptionOn-demand virtual consultationStaffed by emergency-trained providersSmall, walk-in clinics located in retail stores treat simple illnesses, provide preventative servicesTypically staffed by NPs or PAsSmall primary care practice in leased retail spaceService scope covers 80% of typical primary careStaffed by 2-3 providersStandalone facility offering walk-in, extended hour access for acute illness and injury careStaffing varies by locationUCC with ED-level diagnostic capabilities to treat emergent conditionsStaffed by emergency physiciansSatellite full-service emergency department providing full gamut of emergency careOpportunitiesAugment same-day, after-hours accessLow capital costsPotential to foster better provider-patient communicationFeed referralsPotential to support disease management servicesCompressed time to open, startup costsRecruit new patients in underserved areasOffload volumes from congested EDFaster, more pleasant patient experienceLower cost settingPotential to incorporate into accountable care organization strategyMore efficient throughput than EDMarket entry strategyExpand market share in both ED volumes and downstream admissionsImprove payer mixChallengesPotential quality concernsService scope may be limitedQuestionable profitabilityProviders must weigh benefits, drawbacks of direct ownership vs. partnershipsSubscale modelDifficult to scale upCertain patients will still need to travel for select ancillary servicesProfitability can be ambiguousPatient confusion when selecting appropriate care settingOvercome skepticism around patient safetyGenerate sufficient emergent volumes to offset additional costsCompetitive concernsLegislation spurred by cost, overcapacity concernsFuture ProspectsRobust growth forecast as payers cover services and technology advancesStrong growth prospects in light of PCP shortage, ACOs, enhanced quality and convenienceModerately positive outlook primarily due to subscale operating costsClear market need but economics still not attractiveConservative growth outlook given safety and cost concernsHealthy growth opportunityPotential for oversaturation in some marketsSource: Advisory Board research and analysis.
15 Total Number of Medicare-Certified ASCs Strategic Imperative #2 – Rationalizing Procedural CapacityFewer Ambulatory Surgery Centers Coming On LineOnce Dominant Surgery Centers Looking More VulnerableTotal Number of Medicare-Certified ASCsNet percent growth from previous yearNew Centers8.6%Existing Centers7.4%7.7%7.3%4.4%5.7%6.0%2.1%167Allowing 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 BankFebruary 2008Source: MedPAC Data Book, June 2010; “Ambulatory Surgery Centers: Annual Survey Shows Growth Continues to Slow,” Deutsche Bank, February 4, 2008.
16 Building a Medical Home for Chronic Patients Strategic Imperative #3 – Reinforce the Disease Management EnterpriseBuilding a Medical Home for Chronic PatientsCo-Locating Services at AtlantiCare’s Special Care CentersPatient ProfileChronic illness such as diabetes, heart disease, obesity, or asthmaEmployees of union partnering with AtlantiCare or hospital staff1,200 patientsPlans to expand to uninsured populationServices ProvidedHealth coach manages patients’ carePCPs serve as program leadersOn-site specialists include cardiology and psychiatryCo-located with retail pharmacy, lab, radiology, and after hours primary careCase in Brief: AtlantiCare Regional Medical CenterNonprofit health system located in Atlantic City, New JerseySpecial Care Centers (SCC) are patient-centered medical homes focused on chronic diseasesSCC is a partnership between a local union and AtlantiCareSource: Center for the Health Professions, “The Special Care Center – A Joint Venture to Address Chronic Disease,” available atAddress_Chronic_Disease.pdf, accessed March 28, 2011.
17 Playing by Different Rules Rethinking Ambulatory Facility StrategyRethinking Ambulatory Facility DesignMigrating to a Patient-Centered Model
18 Streamline Front End Operations Improving Clinic Design from Front to BackThree Goals of Ambulatory Facility DesignImprove patient arrival and registration processUtilize technology to speed patient visitStreamline patient rooming systemStreamline Front End OperationsDesign the ExamRoom of the Future13Build the right size exam roomFacilitate high quality care delivery through room layoutEnsure patient and caregiver involvement in care processEncourage staff/clinician communication through shared workspacesRemove physician offices to encourage collaborationBuild the appropriate number of exam rooms per provider2Optimize Clinic DesignSource: Advisory Board interviews and analysis.
19 Kiosk Utilization Rates Registration Staff Spaces Kiosks Streamlining Patient Check-InStrategic Placement and Human Support Keys to SuccessKiosk Utilization RatesRegistration Staff Spaces12University of Wisconsin Hospitals and Clinics, West ClinicHospital-based outpatient clinic located in Madison, WIInstalled 2 kiosks in 2007; timing aligned with migration to EpicOriginal location led patients to encounter registration staff first, new location is front and center, eliminating lines for registration counterBeyond registration counter, without framing structureIn front of registration counter, showcased in prominent structureSource: 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.
20 Self-Rooming Patient Flow Map Patient, Room ThyselfSelf-Rooming Process Streamlines Front-End OperationsSelf-Rooming Patient Flow Map#12Check-InNotify TeamCoded CardEasy WayfindingRoom ArrivalPatient checks in at central registrationReceptionist enters patient arrival and room assignment in tracking system, care team notifiedPatient receives color-coded card with room number (or pager if no room available)Patient directed by color-coded signs to neighborhood, then exam roomClinician promptly meets patient in exam roomPark Nicollet Clinic – Chanhassen56,000 SF multispecialty clinic located in Chanhassen, MNOpened new facility in 2005 designed around patient self-rooming , easy wayfinding, care neighborhoods, and patient locator systemSource: 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.
21 Chanhassen Clinic First Floor Plan Waiting Area Seats per Exam Room Self-Rooming Significantly Downsizing Waiting RoomsChanhassen Clinic First Floor PlanWaiting Area Seats per Exam Room1.51Minimized waiting room square footageNote: 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.
22 Streamline Front End Operations Optimize Clinic Design Improving Clinic Design from Front to BackThree Goals of Ambulatory Facility DesignImprove patient arrival and registration processUtilize technology to speed patient visitStreamline patient rooming systemStreamline Front End OperationsDesign the ExamRoom of the Future13Build the right size exam roomFacilitate high quality care delivery through room layoutEnsure patient and caregiver involvement in care processEncourage staff/clinician communication through shared workspacesRemove physician offices to encourage collaborationBuild the appropriate number of exam rooms per providerOptimize Clinic Design2
23 Facilitating Team-Based Care Caregivers at the CoreFacilitating Team-Based CareA Collaborative Work Environment at St. John’s ClinicThe Care Team ModuleFive to seven physicians per moduleUpstaffed from one to two nurses per physicianNurses have taken over many physician tasks, including taking patient histories and care coordinationLPNs and MAs trained to advanced competencies and work with all physiciansCase in Brief: St. John’s Clinic, RollaIntegrated physician arm of Mercy St. John’s Health System, located in MissouriClinic has more than 180,000 visits per year550 physicians, 70 offices, 40 locationsOpened redesigned clinic in 2009 with goals of improving patient experience and efficiency and achieving a team-based care modelSource: The Neenan Group, Advisory Board interviews and analysis.
24 Caregivers Working Side-By-Side Workstations Co-Located in Central BullpenImage courtesy of Anshen+Allen, a part of Stantec.Image courtesy of St. John’s Clinic, Rolla.Advantages of BullpenEnhances communication and camaraderie among staffMaintains sight lines to exam roomsReduces clinical staff footsteps, time spent tracking down colleaguesSource: Anshen+Allen, a part of Stantec; St. John’s Clinic, Rolla; Advisory Board interviews and analysis.
25 Private Physician Office Abolishing the Private Physician OfficeEncouraging Collaboration via Shared Work Spaces at St. John’sBehind Closed DoorsOut in the OpenPrivate Physician OfficeShared Staff LoungeTouchdown SpacePhysicians isolated in individual officesUsed for dictation, charting, meetings, private phone callsTypically 150 SFReplaced private physician offices with shared lounges consisting of 4 work stations, book shelves, and TV; provide “touchdown” spaces in clinic hallwaysAccommodate physicians’ needs for privacy through use of consult rooms, “do not enter” signs on loungeReduced clinic footprint by 4,000 square feet through elimination of private physician officesSource: Advisory Board interviews and analysis.
26 A 5 to 1 Exam Room Ratio at Mass General Pushing toward the New StandardExpanded Care Team Enables Clinic to Run More RoomsA 5 to 1 Exam Room Ratio at Mass GeneralFive exam rooms per care teamNurse practitioners share patient panel with physiciansNurse PractitionerPhysicianMA escorts patient to room and initiates visit; nurse and case manager provide supportNurseMedical AssistantCase ManagerCase in Brief: Massachusetts General Hospital“Ambulatory Practice of the Future” primary care clinic opened in 2010 in new facility adjacent to main hospitalCare model relies on collaboration among multi-disciplinary care teamsClinic is approximately 7,000 SF with 15 exam roomsSource: Advisory Board interviews and analysis.
27 Exam Room to Physician Ratio A Sum Greater Than Its PartsLeveraging the Care Team to Improve EfficiencyA Bygone EraToday’s StandardA Worthy Goal5 to 1Transition to team-based approach to careAll clinicians working at top of licenseSelect physician tasks off-loaded to LPNs and MAsExam Room to Physician Ratioto 11 to 1Consolidation of practicesRise in patient visits due to aging population and increase in chronic conditionsPrimary care physician shortageTimeSource: Advisory Board interviews and analysis.
28 Streamline Front End Operations Optimize Clinic Design Improving Clinic Design from Front to BackThree Goals of Ambulatory Facility DesignImprove patient arrival and registration processUtilize technology to speed patient visitStreamline patient rooming systemStreamline Front End OperationsDesign the ExamRoom of the Future13Build the right size exam roomFacilitate high quality care delivery through room layoutEnsure patient and caregiver involvement in care processEncourage staff/clinician communication through shared workspacesRemove physician offices to encourage collaborationBuild the appropriate number of exam rooms per providerOptimize Clinic Design2
29 Exam Rooms Bursting at the Seams Rightsizing the Exam RoomExam Rooms Bursting at the SeamsTeam-Based, Patient-Centered Care Creating a Tight FitMore People……and More StuffClinicians and CaregiversIT and Clinical EquipmentScale to reduce patient movement and enhance privacyNP/PAPCPPrinter to enable in-room checkoutWide monitor for patient education and information sharingRNSocial WorkerLarge table for inclusive, side-by-side interactionNutritionistLPN/MASpecial equipment carts ECHO, EKG, phlebotomy, casting and splinting, etc.Family MembersHealth CoachMobile diagnostics to reduce patient shufflingSource: 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?
30 Exam Room Size Assessment Finding the “Sweet Spot”Square Feet Ideal for Universal Exam RoomExam Room Size Assessment<90 SF“An Anachronism”Inflexible; limited “wiggle room” to accommodate extra care team member, caregiver, mobile equipment and side-by-side consult100 SF“A Tight Fit”Currently sufficient for most visits but limited flexibility to accommodate team-based care, electronic information sharing110–120 SF“The Sweet Spot”Comfortably accommodates three distinct zones for provider, patient and family, as well as clinical and IT equipment150+ SF“Unnecessaryfor Most”Financially challenging for most practices, used primarily for consult-intensive specialties such as oncologySource: Advisory Board interviews and analysis.
31 Distinct Zones Facilitate Patient-Centric Encounter Optimal Exam Room LayoutDistinct Zones Facilitate Patient-Centric EncounterFamily ZoneAmple seating to accommodate caregiver(s)Separate from supply zone to avoid interference with clinician workflowPatient-Centric Exam Room Zones12’Image courtesy of HKS ArchitectsComputer/Charting ZoneLarge monitor(s) mounted on desk/wall enables equal information sharingTable shape/size facilitates exam triangleMoveable seating to accommodate patient and caregiverOptional in-room printer10’Exam ZoneRoom must be large enough to allow space around the exam tableImage courtesy of SmithGroupSupply/Hand Washing ZoneSeparate area for clinical supply storageSource: SmithGroup; HKS Architects; Advisory Board research and analysis.110’-120’ SF for universal exam roomConsult performed in the roomAvoid 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 otherCertain specialties can use same size room and maintain separate zones but require specific equipment (ENT, Opth, Ortho)
32 Southcentral Foundation “Talking Rooms” “Talking Room” Functions Exam Room Alternatives“Talking Rooms” as Multi-Purpose, Flexible SpacesSouthcentral Foundation “Talking Rooms”“Talking Room” FunctionsLess clinical setting for visits that do not require exam tableSide-by-side consults that promote greater family participationPrivate clinician-clinician interactionsPatient-clinician phone callsAccommodate waiting familiesExam room dimensions and location enable ability to flex space into exam roomSouthcentral Foundation, Anchorage Native Primary Care Center75,000 SF outpatient facility of Alaska-native owned, nonprofit health systemDesigned to be responsive to unique needs and values of the native communityReflects effort to shift care to where it is most appropriately performed, reduce patient anxiety and include extended family in care plansNote: Floorplan courtesy of SouthCentral Foundation and NBBJ.Source: Southcentral Foundation; NBBJ; Advisory Board interviews and analysis.
33 32% 85% Group Visits Enhancing Capacity, Gaining Popularity Consolidated Patient Encounters Maximize Provider ProductivityClinica Campesina Thornton Clinic Floor Plan32%Multiple Individual VisitsIncrease in provider productivity during group visit activity in 20101Single Group Visit85%Patients electing to continue group visitsCase in Brief: Clinica CampesinaPiloted 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 annuallyVisit efficiency maximized through team-based care; PCP present for only 50-75% of group visit slot4,790 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 teamStaff Satisfaction: Reduces repetition of basic diabetes education information; Better patient engagementDemonstrated care quality improvement in certain patient populations3 exam rooms per providerCan vary size of group room depending on number of patients. Ambulatory Practice of the Future has flexible walls in their conference room.
34 Distribution of Ambulatory Care Encounters Virtual Visits Potentially Decreasing Room Demandand Phone Contact on the RiseDistribution of Ambulatory Care Encounters8%Kaiser Permanente Hawaii MembersIncrease in interactions with doctor4%Office Visits~100%26%Phone VisitsDecrease in office visitsCase in Brief: Kaiser Permanente HawaiiIn 2004, Implemented KP HealthConnect EHR and patient portal system in outpatient settingBy 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 consistentSource: 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 Playing by Different Rules Rethinking Ambulatory Facility StrategyRethinking Ambulatory Facility DesignMigrating to a Patient-Centered Model
36 Average Square Footage by Facility Age Industry Migrating to Larger Ambulatory BoxesAverage Square Footage by Facility AgeHealth Care REIT Ambulatory Facilitiesn = 38n = 29n = 64n = 26Source: Health Care REIT.
37 Physician-Centric Era Distribution of Ambulatory Services Putting the Patient at the Center of Facility StrategyHospital and Physician Concerns Dominated Previous ErasHospital-Centric EraPhysician-Centric EraPatient-Centric EraDispersedRising demand for primary care fueling increase of small-scale sitesDistribution of Ambulatory ServicesTechnological innovation, shifting incentives push care to freestanding centersPhysician ownership of facilities fuels outmigration to the suburbsRe-aggregating OP care to achieve economies of scale, promote collaboration, and offer “one-stop shopping”OP surgery, diagnostics delivered in the hospitalMOB space clustered around inpatient facilitiesConcentrated19802010Source: Advisory Board research and analysis.
38 Expanding the Portfolio at Both Ends of the Spectrum Outpatient Facility Prototypes at Cassavetes Health1Comprehensive Multispecialty Center“Nurse in a Box”Barebones PCP OfficeMOB Plus“Hospital Without Beds”Mid-level practitionerLow-acuity urgent careFlu shotsSchool physicals2-5 PCPs providing comprehensive primary careBasic LabBasic imaging5-10 PCPs and specialistsBasic LabBasic imagingLimited Rehab10-15 PCPs and specialistsFull-scale LabAdvanced imagingRehabUrgent careASC30+ PCPs and specialistsAdvanced imagingRehabUrgent careASCOncology servicesFreestanding EDObservation unitWellnessServices OfferedAve. SizeUnder 2,000 SFUnder 10,000 SF10, ,000 SF15, ,000 SF50, ,000 SFAve. Cost$350K - $375KUnder $2.5M$15M - $18M$22M - $25M$45M - $70M1 Pseudonymed 7-hospital system in the Northeast.Source: Advisory Board interviews and analysis.
39 Facility Planning Forum Ambulatory Facility Strategy in the Reform EraMichael HubbleSenior DirectorThe Advisory Board CompanyFacility Planning Forum
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