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Ambulatory Facility Strategy in the Reform Era. Facility Planning Forum. Michael Hubble Senior Director The Advisory Board Company hubblem@advisory.com. Playing by Different Rules. Rethinking Ambulatory Facility Strategy. Rethinking Ambulatory Facility Design.

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slide1
Ambulatory Facility Strategy in the Reform Era

Facility Planning Forum

Michael Hubble

Senior Director

The Advisory Board Company

hubblem@advisory.com

slide2
Playing by Different Rules

Rethinking Ambulatory Facility Strategy

Rethinking Ambulatory Facility Design

Migrating to a Patient-Centered Model

slide3
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

  • 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

slide4
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

CMS issues provisions to Hospital Readmissions Reduction Program

President Obama repeals 1099 reporting requirement from PPACA

HHS releases Meaningful Use regulations

VA Attorney General files first lawsuit against individual mandate

CMS releases proposed rule for Medicare Shared Savings Program

HHS releases Medicare Value-Based Purchasing Program final rule

slide5
Massachusetts Universal Coverage Initiative

Virtually Eliminating the Uninsured

Health Insurance Reform

Source: Division of Health Care Finance and Policy, “Health Care Indicators in Massachusetts,” November 2009; Health Care Advisory Board interviews and analysis.

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

slide6
Preventive Care Utilization Has Increased…

Based on Self-Reported Data, 2006-2009

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.

Utilization of Specific Services, Massachusetts Adults

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

slide7
Building Accountability through Experiments in Payment

Toward Accountable Care

Payment Reform

Source: Health Care Advisory Board interviews and analysis.

Capitation/Shared-Savings Models

Episodic Bundling

Degree of Shared Risk

Hospital-Physician Bundling

Pay-for-

Performance

Care Continuum

slide8
Medicare Shared Savings Program Holding Providers Accountable

Biggest News of the Year?

Source: Health Care Advisory Board interviews and analysis.

  • Shared Savings Payment Cycle

Program in Brief: Medicare Shared Savings Program

Assignment

Patients assigned to ACO based on terms of contract

1

Billing

Providers bill normally, receive standard fee-for-service payments

  • 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

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

slide9
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 - 2008

Percentage of “Active” Physicians Employed by Hospital

Physician Practice Ownership

slide10
Robust Ambulatory Network Central to ACO Ambition

Source: Advisory Board interviews and analysis.

ACO Medical Management Investments

Patient Activation

Post-Acute Alignment

Medical Home Infrastructure

Disease Management Programs

Population Health Analytics

Primary Care Access

Electronic Medical Records

Remote Monitoring

slide11
The New Imperatives for Ambulatory Facility Strategy

Imperative #1

Imperative #2

Imperative #3

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
slide12
Playing by Different Rules

Rethinking Ambulatory Facility Strategy

Rethinking Ambulatory Facility Design

Migrating to a Patient-Centered Model

slide13
Strategic 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

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)

slide14
Assessing Prospects for Evolving Urgent-Emergent Care Models

Source: Advisory Board research and analysis.

Routine Primary Care

Emergent Care

Continuum of Urgent-Emergent Care Models

slide15
Strategic 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 ASCs

2002-2009

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 Bank

February 2008

Net percent growth from previous year

New Centers

8.6%

Existing Centers

7.7%

7.4%

7.3%

4.4%

6.0%

5.7%

2.1%

167

slide16
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

Strategic Imperative #3 – Reinforce the Disease Management Enterprise

  • 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
slide17
Playing by Different Rules

Rethinking Ambulatory Facility Strategy

Rethinking Ambulatory Facility Design

Migrating to a Patient-Centered Model

slide18
Three Goals of Ambulatory Facility Design

Improving Clinic Design from Front to Back

Source: Advisory Board interviews and analysis.

  • 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

Optimize Clinic Design

1

3

2

  • 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
slide19
Source: Advisory Board interviews and analysis.

Beyond registration counter, without framing structure

In front of registration counter, showcased in prominent structure

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

Kiosk Utilization Rates

Strategic Placement and Human Support Keys to Success

Kiosks Streamlining Patient Check-In

Registration Staff Spaces

1

2

slide20
Self-Rooming Process Streamlines Front-End Operations

Source: Advisory Board interviews and analysis.

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

Self-Rooming Patient Flow Map

Patient, Room Thyself

#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

slide21
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

Waiting Area Seats per Exam Room

1.5

1

Minimized waiting room square footage

slide22
Three Goals of Ambulatory Facility Design

Improving Clinic Design from Front to Back

  • 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

slide23
Caregivers at the Core

Source: The Neenan Group, www.neenan.com; Advisory Board interviews and analysis.

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

A Collaborative Work Environment at St. John’s Clinic

Facilitating Team-Based Care

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
slide24
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.

Image courtesy of Anshen+Allen, a part of Stantec.

Image courtesy of St. John’s Clinic, Rolla.

slide25
Source: Advisory Board interviews and analysis.

Encouraging Collaboration via Shared Work Spaces at St. John’s

Abolishing the Private Physician Office

Behind Closed Doors

Out in the Open

Private Physician Office

SharedStaff Lounge

Touchdown Space

  • Replaced private physician offices with shared lounges consisting of 4 work stations, book shelves, and TV; provide “touchdown” spaces in clinic hallways

Physicians isolated in individual offices

Used for dictation, charting, meetings, private phone calls

Typically 150 SF

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

slide26
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

Physician

Nurse Practitioner

MA escorts patient to room and initiates visit; nurse and case manager provide support

Medical Assistant

Case Manager

Nurse

slide27
Leveraging the Care Team to Improve Efficiency

A Sum Greater Than Its Parts

Source: Advisory Board interviews and analysis.

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

2.5-3.0 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

slide28
Three Goals of Ambulatory Facility Design

Improving Clinic Design from Front to Back

  • 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

slide29
Team-Based, Patient-Centered Care Creating a Tight Fit

Exam Rooms Bursting at the Seams

Rightsizing the Exam Room

Source: Advisory Board interviews and analysis.

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

slide30
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

slide31
Distinct Zones Facilitate Patient-Centric Encounter

Optimal Exam Room Layout

Source: SmithGroup; HKS Architects; Advisory Board research and analysis.

Patient-Centric Exam Room Zones

Image courtesy of HKS Architects

Image courtesy of SmithGroup

  • Family Zone
  • Ample seating to accommodate caregiver(s)
  • Separate from supply zone to avoid interference with clinician workflow

12’

  • 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
  • Supply/Hand Washing Zone
  • Separate area for clinical supply storage
slide32
Exam 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

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

  • “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

slide33
Source: Boulder Associates Architects; Advisory Board interviews and analysis.

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: 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

Consolidated Patient Encounters Maximize Provider Productivity

Group Visits Enhancing Capacity, Gaining Popularity

ClinicaCampesina 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

slide34
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

Distribution of Ambulatory Care Encounters

8%

Kaiser Permanente Hawaii Members

Increase in interactions with doctor

4%

Office Visits

26%

~100%

Phone Visits

Decrease in office visits

E-Mail

slide35
Playing by Different Rules

Rethinking Ambulatory Facility Strategy

Rethinking Ambulatory Facility Design

Migrating to a Patient-Centered Model

slide36
Average Square Footage by Facility Age

Health Care REIT Ambulatory Facilities

Source: Health Care REIT.

n = 38

Industry Migrating to Larger Ambulatory Boxes

n = 29

n = 64

n = 26

slide37
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”

slide38
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

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 - 15,000 SF

15,000 - 50,000 SF

50,000 - 100,000 SF

Ave. Cost

$350K - $375K

Under $2.5M

$15M - $18M

$22M - $25M

$45M - $70M

slide39
Ambulatory Facility Strategy in the Reform Era

Facility Planning Forum

Michael Hubble

Senior Director

The Advisory Board Company

hubblem@advisory.com