Mission Critical: Fixing Ambulatory Care

Years ago there were two worlds of outpatient care—what physicians provided in their office and what hospitals offered within a defined facility with limited outpatient services. There were a few exceptions to this model, but outpatient care was usually the add-on to already stressed inpatient departments. Little thought was given to convenience, cost control, or amenities. Now, the proportion of care delivered outside the hospital has grown and the demand for special ambulatory environments drives the healthcare market.

Delivery of ambulatory services takes on greater significance as care has shifted from the inpatient to outpatient setting, and more hospitals consider expanding or building large ambulatory care networks and facilities. With increased capital investment and the complexities of staffing and operations, the strategic costs of not getting it right are risky. Compound all of this by potential changes in financial structure, accessibility, and care delivery oversight, and planning becomes even more daunting.

It is no longer enough to just build space and shift services out of the hospital and hope for success. The future of “American” healthcare as a hospital-centered system for care is rapidly being challenged by a new model focused on prevention, healing, and chronic care delivered in the lowest cost/highest access setting—ambulatory care.

What does this mean for healthcare institutions and those who consult and design for them? How is this different for pediatric institutions compared to adult care? In our recent survey, hospital leaders revealed common issues surrounding ambulatory care that “keep them up at night.” The top response was lower reimbursement.

Other major concerns were:

• Access;
• Facility capacity;
• Coping with technology;
• EMR/IT connectivity;
• Enough staff/providers;
• Managing complexity; and
• Customer service/expectations.

Future trends
Although the future is murky, there are trends illuminating potential realities. Physicians shifting from private to institution-partnered practice are becoming a groundswell. The complexity of managing business, lower reimbursement, and proposed accountable care organizations are driving physicians into large group practices or partnerships with hospitals. Unlike the physician practice buying rush in the 1990s, partnerships being created today are based on services integration and incentives alignment.

These same factors are fueling integration of primary and specialty care networks to manage complex disease entities and focus on constituents’ health. This means different types of facilities will be needed to support the new models. Simultaneously, there will be more centralization of services into larger buildings and decentralization into neighborhood settings.

The financial pressure on care delivery increases with capitated care, services bundling, medical homes, and access expanded for millions of currently uninsured patients. Technological and clinical practice changes accelerating the shift from inpatient environments to less costly outpatient settings require a new business model to understand a refined pricing model and, in some cases, will require building code changes. For example, in pediatrics where sedation is frequently used to reduce anxiety or keep a restless small child immobile during a simple procedure or MRI scan, some state codes require an operating room environment whenever a moderate anesthetic is used. This forces more expensive construction for noninvasive tests.

There will be increased pressure on information technology to expand to meet greater demands for integration of patient information across all settings, access to systems by patients, and new uses of IT, such as home monitoring, telemedicine, and virtual visits. This is changing how care providers interface with each other and the patient. Data-driven performance measures will be required and fuel the need to incorporate performance improvement tools, such as Lean/Six Sigma, into all aspects of the care delivery process and the facilities designed to support outpatient care.