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The Right Mix: Design Considerations for Emergent Care Settings

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Perhaps it’s the millennial in me, but after relocating to the Midwest, it took me over two years and four visits to urgent care before I finally selected a Primary Care Physician (PCP). As a new patient, urgent care became my point of care for its ease of access and affordability, and I’m not alone in this choice. Although an Urgent Care Center (UCC) is traditionally used to treat unexpected illnesses or injuries, according to the Advisory Board Company’s report “The Ambulatory Constellation,” 34% of urgent care patients don’t have a PCP.

Although I’m just one example of a patient and the decision-making process that takes place, I’ll share my approach for choosing unplanned care.

  1. Acuity – My first metric is: How sick am I? Having never been to an ED, my illnesses have been less acute, allowing me to consider where I want to seek unplanned care.
  2. Travel Distance + Provider Availability – For me, a convenient location and availability go hand-in-hand. I’ll travel further to seek care if the physician can see me sooner. Online scheduling options have also reduced my wait time.
  3. Perception of Quality / Experience – Yelp reviews aren’t just for restaurants anymore; almost every business, including healthcare providers, have reviews. On more than one occasion, such reviews have influenced my decision on where to seek care.
  4. Cost – Cost is important to me, but because I know the amount of my co-pay, it isn’t my top concern.

At EUA, we’ve found that decision-making criteria varies by the demographic. When asking co-workers how they make healthcare decisions, one Gen X’er mentioned that she is extremely loyal to her system and doctor, so for her, provider availability and the perception of quality ranks highest, with less focus on travel distance, cost or Yelp reviews.

How Can Health Systems Navigate Emergent Care Offerings?

Recently, I gave a presentation at the American College of Healthcare Executives (ACHE) Wisconsin Chapter’s annual conference regarding “Designing for Patient Access” where we looked at how health systems can improve the on-demand care experience across their customer base.

Driven by reimbursement changes and patient preferences, health systems have evolved from the hospital-attached ED to include Walk-in Clinics, Urgent Care Centers, Free Standing EDs and Micro-Hospitals. By providing a mix of care sites and services, systems can attract new patients by offering a variety of entrance points to their system and providing care efficiently. By treating patients in the most appropriate care setting, providers can reduce ED overcrowding while expanding outpatient services—a win-win for patients and health systems. Five of the most common unplanned care facility types with the top operational and design considerations that I see include the following:

1. Walk-in (Retail) Clinic

The walk-in retail clinic is currently the fastest growing model in the US, as it attracts new patients to a system with a low investment and high convenience.

Key Considerations:

  • Branding + Location – Maintaining consistency of brand in a retail model can prove challenging, but by choosing the right location with high visibility, systems can attract new patients.
  • Open Late – Most patients accessing a retail clinic are doing so after work or on a weekend. Providing extended hours can be a patient satisfier, but staffing can be a concern since one to two staff members are expected to perform all tasks.
  • Small Space – Ensuring acoustical separation between waiting and exam spaces is vital to maintain patient privacy. Using technology to aid the check-in process can reduce overcrowding while also allowing patients to continue shopping while they wait.

2. Urgent Care Center (UCC)

UCCs can treat a wide range of conditions, including many often seen in an Emergency Department, helping to reduce unnecessary ED utilization and improving care experiences.

Key Considerations:

  • Self-Triage – Arriving to the urgent care under their own power, patients must self-triage to decide whether to go to an UCC or an ED. Patient education can improve this decision-making process, but some patients will still require transfer to an ED; providing a means for ambulance access and transfer should be planned early in the design process.
  • Co-locating Opportunities – Joining with primary and specialty care services allows a health system to treat patients more holistically as well as keeping patient referrals within the system. If designed with adjacencies to another clinic, exams rooms can flex during high volume times to maximize utilization and reduce wait times.
  • Billing + Occupancy – At the beginning of design, determine if the facility will use hospital billing, non-hospital billing or a mix of the two, as this will affect building planning. Typically, an UCC is Business Occupancy, but if the facility could eventually transition to an ED, a stricter Institutional Occupancy will be required.

3. Freestanding Emergency Department (FSED)

Within the aforementioned report by the Advisory Board Company, “The Ambulatory Constellation,” FSEDs are a base to building a system’s outpatient services hub, with 54% being hospital satellites.

Key Considerations:

  • Patient Education – With 95% of patients entering under their own power, there may be confusion as to when to seek care at a FSED versus an UCC. With insurance providers often refusing to pay for some non-emergent visits to an ED, determining where to seek treatment is especially important.
  • Construction Cost – Although the cost to build is generally lower than a traditional ED, the cost per patient bed can be greater due to the increased square footage needed to provide appropriate ancillary services such as imaging and lab. This could be mitigated by co-locating with other outpatient services.

4. Micro-Hospital

Becker Hospital Review stated that “Many health systems choose micro-hospitals because they can provide more services to a community than a FSED, and their activity levels are much broader than your average urgent care center.”

Key Considerations:

  • Location – Choose the correct location through a needs analysis to determine the types of services that should be provided to avoid scope creep and to ensure ample inpatient volumes. CMS requires a minimum census of two to be surveyed as a hospital.
  • Billing – As a micro-hospital generates its own hospital campus definition, outpatient facilities within 250 yards are exempt from site-neutral payments.
  • New Market – A micro-hospital can be a great opportunity to enter a new market at a low cost as most are under 50,000 sq ft with about 10 inpatient beds.

5. Hospital-Attached Emergency Department

Ideally, having a mix of access points can decant volumes from the ED and minimize overcrowding.

Key Considerations:

  • Admission – Determine the model for triage and waiting. Sub-waits within the ED can improve patient flow.
  • Ancillary Services – Consider adding dedicated lab and imaging modalities to decrease turnaround times and improve patient wait times.
  • Discharge – Some patients will need to remain under observation for longer periods yet don’t require admission. In this case, adding a short stay unit for stays under 24 hours can improve patient flow by moving patients out of treatment spaces.

As health systems continue to evolve, patients will have even more choices on how and where they can access healthcare. As industry leaders it is important to understand these coming changes and build a flexible system with multiple access points to provide the best affordable care to patients. Today, most systems are using a combination of these settings to meet patient needs. I’d love to hear from others on how you are seeing changing demographics influence emergent care access strategies.

Emily McNamara, AIA, LEED AP BD+C
Senior Project Architect

Emily McNamara, AIA, LEED AP BD+C, is a Senior Project Architect with EUA's Healthcare Studio in the Milwaukee office. She loves to cook, especially when the food comes from her own garden.

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