In the first two parts of this three-part series (Part 1, Part 2), we explored the constraints and opportunities during the healthcare sector’s transition in the changing regulatory environment. At a global level, we concluded that there are two fundamental strategies that appear to be the key to the success of future accountable care organizations (ACOs): bringing health to the populace and capitalizing on the potentials inherent to active living principles in designing the physical setting of the continuum of care. 

While doing so, we built in the assertion that, irrespective of the direction the healthcare sector adopts (ACOs or some other form), the main solution to the current problem is to reduce the cost of care. The focus of Part 2 was on acute care facilities. In this part, we will focus on the pre-acute and post-acute care settings, which are expected to provide a considerable chunk of services to the future population in the quest for reducing healthcare costs. What are the physical design implications? Will there be any necessity for physical design changes in these settings?  

Articulating physical design interventions warrants a closer look at the main challenges. Two of the fundamental avenues toward cost reduction are to (a) keep people well through health promotion and (b) provide more care at a lower cost in pre- and post-acute care settings. That includes reducing the impulse of a sizable portion of the current population in treating the emergency department as their primary care setting.

In response, almost every acute care provider organization has embarked upon the task of developing relationships with providers in pre- and post-acute care settings. It is a challenging task that is, nevertheless, acknowledged as the key step in providing cost-efficient care. 

These emerging configurations of provider organizations are predicated on one vital assumption/ precondition—that the population at-large (healthy as well as the ill and injured) will maintain an appropriate care regimen depending on their health status, including regular checkups and treatments as necessary. This will ensure maintaining health, preventing illness, and reducing the chance of acute illness, which may require long hospitalization and expensive treatments. 

Some contemporary developments already are challenging this premise. For instance, rising out-of-pocket expenses for a clinic visit (originating from deductibles and co-pay rate increases) are a formidable challenge that may act as a disincentive. For many, it is in addition to the problem of physical access to a provider. In this context, if a care environment is perceived as unsafe, stressful, or cold, the combination of financial, cultural, and environmental impediments could almost guarantee non-participation of a section of the population (those who are not critically ill or in immediate need of care) in preventive or timely health care.

The challenge in diverting non-emergent patients away from the emergency department may, in such a case, continue to exist despite the formation of extensive networks of provider organizations. 

The physical environment is not a panacea for all problems. However, for a sizable segment of the population, the physical environment of care could prove to be the tipping factor between maintaining and not maintaining a regular health assessment and/or treatment regime. This is especially true for the ones who are not in ill health (and hence needing only preventive care and health maintenance) or those who are able to manage their daily lives despite ill health (procrastinating care until reaching acute conditions).

How could the physical design, in conjunction with other factors, motivate this segment, specifically, and the entire population, generally, to maintain health and prevent (emergence or reemergence of) acute illness? 

One potential solution relates to our discussions in the first part of this series—getting the service to the population, as opposed to the population making an effort to go to the service, and incorporating active living concepts. Community integration, access, and active living need to be key drivers of the design of the care environments.

Integration of care settings with destinations that people use as part of their day-to-day living offers a better chance at compliance than isolated, free-standing clinics and medical buildings. Such destinations could include shopping malls as well as other civic and public facilities such as the library, community centers, theaters, and business districts, among others. Further, locating these facilities proximal to public transit (where available) addresses the dual domains of access and active living. 

Key points:

• Integrate with civic and public facilities—destinations that people visit as part of their day-to-day existence.
• Locate proximal to public transit (where available) to address the issues of access and active living.
• Incorporate physically active options in the design of these facilities to motivate and develop a culture of active living.

The second area pertains to the quality of the physical environment in the pre- and post-acute care settings. Even with appropriate access and community integration, the quality of a physical environment could be a deterrent to a visit. The role of the physical environment in contributing to quality care in inpatient settings has undergone broader scientific examination than non-acute care settings. However, most principles of quality- and patient-focused care are as valid in non-acute as in acute care settings. Patient and staff stress, infection, anxiety, wayfinding and other factors affecting quality of care in inpatient settings also affect quality of care in pre- and post-acute care settings.

Numerous studies on clinic waiting areas show the association between the quality of physical environment and such outcomes as perceived quality of care, anxiety level, inclination to recommend the facility to others, and other outcomes of importance. It is true that non-acute settings have not been researched widely (as reflected in the number of scientific publications). However, most of the associations between the physical environment and patient and/or staff outcomes should hold true. What is unknown is the magnitude of such association (or the degree of impact)—which should ideally drive the next batch of research in these settings. 

Key point:

• Inform design decisions with the evidence available on acute care settings. All learning related to patient-focused care and therapeutic environments pertaining to the inpatient care units hold true for pre- and post-acute care settings. 

In essence, as the healthcare business model moves from treating illness to managing health, there will be an increasing need to attract healthy and non-acute patients to their providers such that they maintain and adhere to a care regimen that reduces the need for acute care.

Stakeholders in the entertainment and leisure industries have long mastered the technique of triggering repeat visits by their patrons. For instance, entities such as Disney have established scientific protocols in continuously examining and modifying aspects of the Disney experience that trigger repeat visits. For a large segment of the population, the healthcare industry may find it worthwhile to first under
stand what deters a repeat visit, and perhaps also develop creative ideas regarding things or events that could trigger subsequent visits, and hence adherence to the appropriate health maintenance or treatment regimen.

The physical environment of care could play a significant role in designing the triggers. Moreover, integrating care settings in civic, entertainment and other community facilities offers the potential of developing novel attractions. 

Key point:

Understand deterring and attracting factors. Learn from the entertainment and leisure industries.

In this context, large healthcare providers may need to consider much more than developing care alliances with pre- and post-acute providers. They may need to also think about the physical environment in which their alliance partners in the non-acute spectrum deliver care. Not considering this aspect could lead to missing out on a substantial proportion of the population who may continue to treat the emergency department as their primary care setting, and the healthy population not motivated enough to schedule a regular trip to the primary care provider for health maintenance and illness prevention. 

See the following links for Part 1 and Part 2 of this series:

http://healthcaredesignmagazine.com/article/accountable-care-organizations-part-1

http://healthcaredesignmagazine.com/article/accountable-care-organizations-part-2

Dr. Debajyoti Pati, Ph.D., FIIA, LEED AP, is vice president, director of research at HKS Inc. He can be reached at dpati@hksinc.com.