© 2011 The Advisory Board Company • www.advisory.com
Ambulatory Facility Strategy in the Reform Era
FACILITY PLANNING FORUM
Michael HubbleSenior DirectorThe Advisory Board [email protected]
© 2011 The Advisory Board Company • www.advisory.com
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IIIIIIIV
Road Map for Discussion
Playing by Different Rules
Rethinking Ambulatory Facility Strategy
Rethinking Ambulatory Facility Design
Migrating to a Patient-Centered Model
© 2011 The Advisory Board Company • www.advisory.com
3
Health Systems Placing Big Bets on Ambulatory Expansion
Hospital Outpatient Strategy circa 2007
Source: Bank of America, “Health Care Facilities,” Equities Research, July 2007: Advisory Board interviews and analysis.
Planned Hospital Expansions Within Next Two Years
n=199
Principal Drivers of Outpatient Investment
34%
46%
4%
16%
Neither
InpatientOutpatient
Both80% of hospitals were planning outpatient expansion
Capturing profitable outpatient business in new markets
Blunting competition from physician-owned facilities
Building a platform for a future inpatient facility
Creating new feeders for the inpatient enterprise
© 2011 The Advisory Board Company • www.advisory.com
4
From Health Care Reform to Payment Reform
Hard to Believe It Was Just 2 Years Ago…
Source: Health Care Advisory Board interviews and analysis.
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
© 2011 The Advisory Board Company • www.advisory.com
5
Massachusetts Universal Coverage Initiative
Virtually Eliminating the UninsuredHealth Insurance Reform
Massachusetts Coverage Expansion
Cumulative Increase in Insured Massachusetts Residents
Thousands
114
202
367425 421
• 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 subsidies87% 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.
© 2011 The Advisory Board Company • www.advisory.com
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Preventive Care Utilization Has Increased…
Utilization of Specific Services, Massachusetts AdultsBased on Self-Reported Data, 2006-2009
Fall 2006 Fall 2007 Fall 2008 Fall 2009
70%78%
51% 53%
55% 58%
34% 34%
Preventive Care Specialist VisitTook Any Rx Drugs Any ED Visit
n = 13,150
Preventive Care
Took Any DrugSpecialist Visit
Percent Change in Utilization
9.6%Preventive Care
4.1%Took Any Drug
5.5%Specialist Visit
ED 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 2010 29:6 1234-1240; Health Care Advisory Board interviews and analysis.
© 2011 The Advisory Board Company • www.advisory.com
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Building Accountability through Experiments in Payment
Toward Accountable CarePayment Reform
Source: Health Care Advisory Board interviews and analysis.
Degree of Shared Risk
Care Continuum
Pay-for-Performance
Hospital-Physician Bundling
Episodic Bundling
Capitation/Shared-Savings Models
© 2011 The Advisory Board Company • www.advisory.com
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Medicare Shared Savings Program Holding Providers Accountable
Biggest News of the Year?
Shared Savings Payment Cycle
2
BillingProviders bill normally, receive standard fee-for-service payments
1Assignment
Patients assigned to ACO based on terms of contract
3Target Actual
ComparisonTotal cost of care for assigned population compared to risk-adjusted target expenditures
4
BonusIf total expenses less than target, portion of savings returned to ACO
5
DistributionACO responsible for dividing bonus payments among stakeholders
Program in Brief: Medicare Shared Savings Program• 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
Source: Health Care Advisory Board interviews and analysis.
© 2011 The Advisory Board Company • www.advisory.com
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Reform Accelerates Trend of Practice Acquisition by Hospitals
Shifting from Competitors to Collaborators
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.
2002 - 2008Physician Practice Ownership
2000 2004 2008 2012 (E)
5%8%
15%
24%
18%22%
31%
40%
Specialists PCPs
Percentage of “Active” Physicians Employed by Hospital
2002 2003 2004 2005 2006 2007 20080%
25%
50%
75%
100%
Physicians Hospitals
© 2011 The Advisory Board Company • www.advisory.com
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Robust Ambulatory Network Central to ACO Ambition
Source: Advisory Board interviews and analysis.
ACO Medical Management Investments
Remote Monitoring
Electronic Medical Records
Medical Home Infrastructure
Primary Care Access
Population Health Analytics
Patient Activation
Post-Acute Alignment
Disease Management Programs
© 2011 The Advisory Board Company • www.advisory.com
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The New Imperatives for Ambulatory Facility Strategy
Expand the Front End of the Delivery System
Imperative #2Reinforce the Disease
Management Enterprise
Imperative #1Rationalize Procedural and Imaging Capacity
Imperative #3
• 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
© 2011 The Advisory Board Company • www.advisory.com
12
IIIIIIIV
Road Map for Discussion
Playing by Different Rules
Rethinking Ambulatory Facility Strategy
Rethinking Ambulatory Facility Design
Migrating to a Patient-Centered Model
© 2011 The Advisory Board Company • www.advisory.com
13Strategic Imperative #1 – Expanding Access to Primary Care
Source: Advisory Board interviews and analysis.Note: Image courtesy of Kaiser Permanente.
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
Kaiser Permanente Micro-Clinic Core Model
Kaiser Permanente Embracing New PCP Practice Model
Micro-Clinics – Coming to a Storefront Near You
2-3 providers (mix of MDs, NPs or PAs) plus receptionist
No imaging, pharmacy, lab, consult (optional add-ons)
4 exam rooms, waiting room, clean utility room
On-Site Providers
Clinic Space
Limited Ancillary Services
© 2011 The Advisory Board Company • www.advisory.com
14Assessing Prospects for Evolving Urgent-Emergent Care Models
Source: Advisory Board research and analysis.
Routine Primary 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• Staffed by emergency
physicians
Opportunitie
s
• Augment same-day, after-hours access
• Low capital costs• Potential to foster
better provider-patient communication
• Augment same-day, after-hours access
• Feed referrals• Potential to support
disease management services
• Compressed time to open, startup costs • Potential to foster
better provider-patient communication• 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
• Offload volumes from congested ED
• More efficient throughput than ED
• Market entry strategy
• Offload volumes from congested ED• Expand market share
in both ED volumes and downstream admissions
• Improve payer mix
Challenge
s
• 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
• Overcome skepticism around patient safety• 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
Emergent CareContinuum of Urgent-Emergent Care Models
© 2011 The Advisory Board Company • www.advisory.com
15Strategic Imperative #2 – Rationalizing Procedural Capacity
Source: MedPAC Data Book, June 2010; “Ambulatory Surgery Centers: Annual Survey Shows Growth Continues to Slow,” Deutsche Bank, February 4, 2008.
Allowing Demand to Catch Up with Supply
Total Number of Medicare-Certified ASCs2002-2009
Once Dominant Surgery Centers Looking More Vulnerable
Fewer Ambulatory Surgery Centers Coming On Line
“[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 2008
2002 2003 2004 2005 2006 2007 2008 2009
305 367 369 355 332 347 273
3,5123,814
4,1064,404
4,6544,932 5,151 5,260
7.7%8.6%
167
7.4% 7.3%5.7% 6.0%
4.4%
2.1%
New Centers
Existing Centers
Net percent growth from previous year
© 2011 The Advisory Board Company • www.advisory.com
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Source: Center for the Health Professions, “The Special Care Center – A Joint Venture to Address Chronic Disease,” available at http://www.futurehealth.ucsf.edu/Content/29/201011_The_Special_Care_Center_A_Joint_Venture_to_Address_Chronic_Disease.pdf, accessed March 28, 2011.
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
Co-Locating Services at AtlantiCare’s Special Care Centers
Building a Medical Home for Chronic Patients
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
Strategic Imperative #3 – Reinforce the Disease Management Enterprise
© 2011 The Advisory Board Company • www.advisory.com
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IIIIIIIV
Road Map for Discussion
Playing by Different Rules
Rethinking Ambulatory Facility Strategy
Rethinking Ambulatory Facility Design
Migrating to a Patient-Centered Model
© 2011 The Advisory Board Company • www.advisory.com
18
Three Goals of Ambulatory Facility Design
Improving Clinic Design from Front to Back
Source: Advisory Board interviews and analysis.
2 Optimize Clinic Design
• Encourage staff/clinician communication through shared workspaces
• Remove physician offices to encourage collaboration
• Build the appropriate number of exam rooms per provider
1 Streamline Front End Operations
• Improve patient arrival and registration process
• Utilize technology to speed patient visit
• Streamline patient rooming system
3 Design the Exam Room of the Future
• Build the right size exam room
• Facilitate high quality care delivery through room layout
• Ensure patient and caregiver involvement in care process
© 2011 The Advisory Board Company • www.advisory.com
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Source: Advisory Board interviews and analysis.
1 Beyond registration counter, without framing structure2 In front of registration counter, showcased in prominent structure
University of Wisconsin Hospitals and Clinics, West Cl inic• 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
Kiosk Utilization Rates
Strategic Placement and Human Support Keys to Success
Kiosks Streamlining Patient Check-In
3%
30%
1 2
Registration Staff Spaces
Without Kiosks
With 2 Kiosks
Goal
6
4
2
© 2011 The Advisory Board Company • www.advisory.com
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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
Source: Advisory Board interviews and analysis.
Park Nicollet Cl inic – 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
Self-Rooming Patient Flow Map
Self-Rooming Process Streamlines Front-End Operations
Patient, Room Thyself
#12
Clinician promptly meets patient in exam room
Check-In Notify Team Coded Card Easy Wayfinding Room Arrival
© 2011 The Advisory Board Company • www.advisory.com
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Source: BWBR Architects; Advisory Board interviews and analysis.Note: Image courtesy of BWBR Architects.
Chanhassen Clinic First Floor Plan
Self-Rooming Significantly Downsizing Waiting Rooms
0.5
1.5
1
Minimized waiting room square footage
Waiting Area Seats per Exam Room
© 2011 The Advisory Board Company • www.advisory.com
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Three Goals of Ambulatory Facility Design
Improving Clinic Design from Front to Back
1 Streamline Front End Operations
3 Design the Exam Room of the Future
• Build the right size exam room
• Facilitate high quality care delivery through room layout
• Ensure patient and caregiver involvement in care process
• Improve patient arrival and registration process
• Utilize technology to speed patient visit
• Streamline patient rooming system
• 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
© 2011 The Advisory Board Company • www.advisory.com
23Caregivers at the Core
Source: The Neenan Group, www.neenan.com; Advisory Board interviews and analysis.
Case in Brief: St. John’s Cl inic, 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
A Collaborative Work Environment at St. John’s Clinic
Facilitating Team-Based Care
• 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
The Care Team Module
© 2011 The Advisory Board Company • www.advisory.com
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Workstations Co-Located in Central Bullpen
Caregivers Working Side-By-Side
Source: Anshen+Allen, a part of Stantec; St. John’s Clinic, Rolla; Advisory Board interviews and analysis.
Advantages of Bullpen
Enhances communication and camaraderie among staff
Maintains sight lines to exam rooms
Reduces clinical staff footsteps, time spent tracking down colleagues
Image courtesy of Anshen+Allen, a part of Stantec. Image courtesy of St. John’s Clinic, Rolla.
© 2011 The Advisory Board Company • www.advisory.com
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Source: Advisory Board interviews and analysis.
Encouraging Collaboration via Shared Work Spaces at St. John’s
Abolishing the Private Physician Office
Behind Closed Doors
Physicians isolated in individual offices
Used for dictation, charting, meetings, private phone calls
Typically 150 SF
Out in the Open
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
Private Physician Office Shared Staff Lounge Touchdown Space
© 2011 The Advisory Board Company • www.advisory.com
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Source: Advisory Board interviews and analysis.
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
A 5 to 1 Exam Room Ratio at Mass General
Expanded Care Team Enables Clinic to Run More Rooms
Pushing toward the New Standard
Five exam rooms per care team
Nurse practitioners share patient panel with physicians
MA escorts patient to room and initiates visit; nurse and case manager provide support
Nurse Practitioner Physician
Nurse Medical Assistant
Case Manager
© 2011 The Advisory Board Company • www.advisory.com
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5 to 1
Leveraging the Care Team to Improve Efficiency
A Sum Greater Than Its Parts
Source: Advisory Board interviews and analysis.
1 to 1
2.5-3.0 to 1
Time
Exam Room to Physician
Ratio
Consolidation of practicesRise in patient visits due to aging
population and increase in chronic conditions
Primary care physician shortage
Transition to team-based approach to care
All clinicians working at top of license
Select physician tasks off-loaded to LPNs and MAs
A Bygone Era Today’s Standard A Worthy Goal
© 2011 The Advisory Board Company • www.advisory.com
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Three Goals of Ambulatory Facility Design
Improving Clinic Design from Front to Back
1 Streamline Front End Operations
• Improve patient arrival and registration process
• Utilize technology to speed patient visit
• Streamline patient rooming system
3 Design the Exam Room of the Future
• 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
© 2011 The Advisory Board Company • www.advisory.com
29
Team-Based, Patient-Centered Care Creating a Tight Fit
Exam Rooms Bursting at the SeamsRightsizing the Exam Room
Source: Advisory Board interviews and analysis.
More People…
PCPNP/PA
RN
LPN/MA
Health Coach
Nutritionist
Social Worker
Family Members
…and More Stuff
Printer to enable in-room checkout
Wide monitor for patient education and information sharing
Large table for inclusive, side-by-side interaction
Mobile diagnostics to reduce patient shuffling
Special equipment carts ECHO, EKG, phlebotomy, casting and splinting, etc.
Scale to reduce patient movement and enhance privacy
Clinicians and Caregivers IT and Clinical Equipment
© 2011 The Advisory Board Company • www.advisory.com
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110-120 Square Feet Ideal for Universal Exam Room
Finding the “Sweet Spot”
Source: Advisory Board interviews and analysis.
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
© 2011 The Advisory Board Company • www.advisory.com
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Distinct Zones Facilitate Patient-Centric EncounterOptimal Exam Room Layout
Source: SmithGroup; HKS Architects; Advisory Board research and analysis.
Patient-Centric Exam Room Zones
12’
10’
Supply/Hand Washing Zone• Separate area for clinical
supply storage
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
Exam Zone• Room must be
large enough to allow space around the exam table
Family Zone• Ample seating to
accommodate caregiver(s)
• Separate from supply zone to avoid interference with clinician workflow
Image courtesy of HKS Architects
Image courtesy of SmithGroup
© 2011 The Advisory Board Company • www.advisory.com
32Exam Room Alternatives
Source: Southcentral Foundation; NBBJ; Advisory Board interviews and analysis.
Note: Floorplan courtesy of SouthCentral Foundation and NBBJ.
Southcentral Foundation “Talking Rooms”
“Talking Rooms” as Multi-Purpose, Flexible Spaces
Exam room dimensions and location enable
ability to flex space into exam
room
“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
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
© 2011 The Advisory Board Company • www.advisory.com
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Source: Boulder Associates Architects; Advisory Board interviews and analysis.
1 4,790 patients seen in 862 group visits, individual visit slots equivalent of 3,625.Note: Floor plan courtesy of Boulder Associates Architects.
Case in Brief: Cl inica 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
Consolidated Patient Encounters Maximize Provider Productivity
Group Visits Enhancing Capacity, Gaining Popularity
Clinica Campesina Thornton Clinic Floor Plan
Single Group Visit
Multiple Individual Visits32%
Increase in provider productivity during group visit activity in 20101
85%Patients electing to continue group visits
© 2011 The Advisory Board Company • www.advisory.com
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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.
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
E-Mail and Phone Contact on the Rise
Virtual Visits Potentially Decreasing Room Demand
26%Decrease in office visits
Distribution of Ambulatory Care EncountersKaiser Permanente Hawaii Members
1999 2007
66%
30%Office Visits~100%Phone Visits
4%
8%Increase in interactions with doctor
© 2011 The Advisory Board Company • www.advisory.com
35
IIIIIIIV
Road Map for Discussion
Playing by Different Rules
Rethinking Ambulatory Facility Strategy
Rethinking Ambulatory Facility Design
Migrating to a Patient-Centered Model
© 2011 The Advisory Board Company • www.advisory.com
36
Average Square Footage by Facility AgeHealth Care REIT Ambulatory Facilities
Source: Health Care REIT.
n = 380-5 Years 6-10 Years 11-20 Years 20+ Years
88,973
56,39350,088
42,889
Industry Migrating to Larger Ambulatory Boxes
n = 29 n = 64 n = 26
© 2011 The Advisory Board Company • www.advisory.com
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Hospital and Physician Concerns Dominated Previous Eras
Putting the Patient at the Center of Facility Strategy
Source: Advisory Board research and analysis.
Hospital-Centric Era Physician-Centric Era Patient-Centric Era
1980 2010
Distribution of Ambulatory
Services
Concentrated
Dispersed
• OP surgery, diagnostics delivered in the hospital
• MOB space clustered around inpatient facilities
• Technological innovation, shifting incentives push care to freestanding centers
• Physician ownership of facilities fuels outmigration to the suburbs
• Rising demand for primary care fueling increase of small-scale sites
• Re-aggregating OP care to achieve economies of scale, promote collaboration, and offer “one-stop shopping”
© 2011 The Advisory Board Company • www.advisory.com
38
Expanding the Portfolio at Both Ends of the Spectrum
Source: Advisory Board interviews and analysis. 1 Pseudonymed 7-hospital system in the Northeast.
Outpatient Facility Prototypes at Cassavetes Health1
“Nurse in a Box”
Barebones PCP Office
MOB Plus
Comprehensive Multispecialty
Center
“Hospital Without Beds”
Services Offered
Ave. SizeAve. Cost
•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
Under 2,000 SF Under 10,000 SF 10,000 - 15,000 SF 15,000 - 50,000 SF 50,000 - 100,000 SF
$350K - $375K Under $2.5M $15M - $18M $22M - $25M $45M - $70M
© 2011 The Advisory Board Company • www.advisory.com
Ambulatory Facility Strategy in the Reform Era
FACILITY PLANNING FORUM
Michael HubbleSenior DirectorThe Advisory Board [email protected]
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