Urgent Care: Right Here, Right Now
Although in existence for decades, urgent care has seen a resurgence in recent years, thanks largely to a provider push toward outpatient treatment and the hole that urgent care stands to fill in the overall preventive health puzzle. It also answers growing demand from patients seeking more convenient care options that don’t require a trip to the ED or a primary care physician, especially outside normal business hours.
And like any product, as demand grows, so too have the models offered. Subsequently, the definition of exactly what urgent care is—clinics staying open into the evening, standalone sites in retail corridors, “micro hospitals” with colocated service lines—remains anything but clear. “We see a real push for getting services out in the community universally, all the way across big health systems down to independent groups,” says Todd Robinson, executive vice president and principal at ESa (Nashville). “It’s not something new, but it’s really caught fire.”
And as urgent care continues to grow and evolve, the spaces supporting it are taking new shape, too. Answering requirements for operational efficiency and meeting patient expectations has risen to the top of designers’ to-do lists, all while creating a truly branded and adaptable environment. It’s a recipe that project teams continue to refine as urgent care comes closer and closer to pushing the ED aside to become many healthcare institutions’ new front door.
For Erdman (Madison, Wis.), several clients, including large, integrated health systems, are strategically deploying urgent care facilities in their own markets as well as looking to the model for growth nationally. For those systems in particular, it’s all about identifying and attaching new patients to the organization, says Rustin Becker, executive vice president at Erdman. “It’s kind of a land grab as systems become more focused on population health. And the fundamental piece to that is, how do you provide access?” Becker says.
And while access to new patients is part of it, Dr. Scott Brady, senior medical director and CEO of Centra Care, the urgent care division for the Adventist Health System that primarily serves Florida with additional sites in Kansas and Maryland, says Centra Care was started 35 years ago as a way to provide convenient, quality care to existing patients. “There’s a significant percentage of people who don’t have a primary care doctor and don’t want to use a primary care doctor for their routine medical needs, especially when you start getting into the Millennials and Gen-Xers.”
All shapes and sizes
Exactly what form an urgent care solution takes varies widely, though. Erdman, for example, is mostly designing urban infill projects, largely in commercial or retail space, with very few greenfield projects. However, more complex new builds are starting to define the next wave of urgent care.
“While we’re still seeing a few of the smaller versions of what urgent care is—which is a 5,000- to 10,000-square-foot clinic that’s open late night and has minimal secondary services like lab and imaging—those are really trending away and [the market] seems to be going to a more inclusive model, which is urgent care, primary care, lab, and imaging rolled into one,” says John Seely, senior associate vice president for CallisonRTKL (Dallas).
CallisonRTKL is the designer for the Warren Clinic project in the Tulsa, Okla., area, an example of this inclusive solution, which includes three completed sites and three additional locations projected for completion in the near future.
A significant benefit to the model is the ability to avoid overbuilding to accommodate occasional spikes in use, such as during flu season. “If you design an urgent care center around that peak, then much of the year that urgent care side is seeing a fraction of the volumes that it was designed for. But if you design it in a cluster around primary care so that after-hours urgent care can flex into what was used for primary care during the day, you get a lot of benefit,” Seely says.
However, expectations for flexing between primary and urgent care could come with limitations, says Centra Care’s Brady. “When you get into complex disease management and a medical home model that’s really at the heart of primary care, then you’re describing a different staffing model and a different business model [than urgent care],” he says. “There’s some crossover, but it’s not apples and apples. Could you colocate those in the same box? Definitely.”
Shannon Bambery, medical planner with BWBR (Saint Paul, Minn.), says colocation is gaining traction on the ED front, too, with larger systems recognizing the benefit of combining emergency and urgent care services on one site. For starters, the move combats the 40 to 50 percent of patients presenting in the ED who are classified as those who, basically, can wait. “If all you do is turn them away or make them sit six hours to get their broken arm set, you’re really missing an opportunity. You’ve got them at your door, so how do you turn that into an ongoing relationship?” he says.
The solution in some cases is a 24-hour freestanding ED with urgent care, providing round-the-clock access for patients and the ability to properly triage them, making sure the chest pain patients aren’t presenting to urgent care and the earaches aren’t presenting to the ED—not only for better care delivery but to simply keep patients out of the much more expensive ED environment when possible.
Gundersen Health System in LaCrosse, Wis., completed a new hospital tower in 2014 that includes a combined ED and urgent care. In addition to combatting the safety issues that go along with true emergency cases landing in an urgent care that isn’t equipped to properly care for them, it’s “a huge inefficiency and overutilization of the ED to have all these patients coming in with very minor things when we may have more serious patients in the waiting room,” says Stephanie Hill, clinical manager of Gundersen Emergency Services.
But there can be downfalls. For example, while the colocation at Gundersen solved several problems, it doesn’t allow the flexibility between room uses that was originally envisioned due to reimbursement differences between the ED and urgent care spaces. “We have to stay pretty true to our rooms. That was something that wasn’t completely understood when this initial model was designed, so we’ve had to adjust a little bit,” Hill says.
Creating an experience
No matter the facility type chosen, experts agree that the look and feel of these spaces will go a long way in creating not just a brand but the desired patient experience. “The appearance of these clinics makes a huge difference in giving people a sense of confidence and comfort,” says Diana Kissil, senior interior designer at SmithGroupJJR (San Francisco).
Kissil worked with Golden Gate Urgent Care, a recent physician-owned endeavor, to launch a new urgen
t care system in the Bay Area. Restricted by San Francisco’s requirements for retail signage on building exteriors, drawing patients in meant bringing the inside out. “A design was developed that would be very eye-catching to passengers in cars as well as pedestrians, and was recognizable day and night,” she says. The frontages of the buildings are largely glass, with waiting spaces stretched across the storefronts.
The other mandate from Golden Gate was to design a space that was unlike any other medical space that patients might have seen, avoiding the hospitality and residential themes so prevalent in hospitals. “This is not a spa, this is not a home; this is an efficient, no-nonsense medical care environment and the design was meant to depict that. So it’s streamlined spaces, it’s very unfussy, it’s very contemporary. There’s not one element of wood, be it real or artificial, in the space. It’s hospitable, but the space isn’t hospitality. That’s not what this is about,” Kissil says.
And what patients encounter once they’re inside is just as important.
At Gundersen, a shared registration desk for the ED and urgent care is used with two triage rooms to ensure patients land in the right spot. Waiting rooms as well as smaller sub-waiting and consult rooms were included to provide more privacy; a financial counseling room and checkout room serve patients on their way out. “When [patients] are on their way in, we just want to know what’s wrong with them and get them back, because they could be really sick,” Hill says.
But eliminating wait times altogether is usually the goal. That was the case for Warren Clinic, which was designed with a decentralized waiting model: Patients and visitors are provided with chairs adjacent to exam rooms to move quickly into the room once it’s vacated. For Golden Gate Urgent Care, SmithGroupJJR took a different approach to combat urgent care’s usual tight waiting quarters by instead expanding a central waiting space, with a reception desk at one end for a sense of privacy and a checkout area with a privacy panel.
“I think of an urgent care 20 years ago as pretty austere and not a place you want to spend much time, but you go because you don’t want to spend a lot of time. The environments that are being developed today are a lot nicer and make the experience from a patient standpoint a lot better,” says Matt Manning, senior designer and manager at ESa.
And those environments are usually built around brand. The branding of urgent care generally takes one of two routes: either supporting and communicating an overarching parent system or establishing something unique (either for independent providers or those attached to a system).
Consistency across sites is key, too, says Mike McKay, vice president and senior architect at Erdman, noting that clients are requesting a prototype for layout and design that can essentially be applied to any location and building type. To that end, Erdman has developed an urgent care playbook for clients that’s adaptable to different shell constructions, column spacings, and so on. Similarly, the Warren Clinic design is a modular prototype.
In and out
Once patients are inside the exam rooms, it’s oftentimes less about the space itself and more about operations and creating efficiency in the treatment process. “We want people to get from door to door in less than an hour and we want their wait time before being seen by a physician to be measured in minutes,” Brady says of his goals for the planning and design of Centra Care locations.
At Warren Clinic, an onstage/offstage model was used, with imaging and lab located close to urgent care since they’re so frequently used. Patients enter exam rooms from a public corridor on the building perimeter, while caregivers enter a door on the opposite side of the exam room from the interior staff core. The same model was used at Gundersen. “This feels different from before, when a lot of times patients were walking right through where I’m doing my work,” Hill says.
Providing open care team stations that support an integrated approach is picking up steam, too, says McKay. However, he says that use of the onstage/offstage model often depends on the client and market being served. For example, some providers prefer to have sight lines into exam rooms and patient circulation around the staff core. That’s what was requested for the Golden Gate project: “Having visual supervision of the space—not for security but for patient care—was important,” Kissil says.
Whether built as a part of a colocated service line or strictly as an urgent care site, facilities designed today all must answer healthcare’s overarching call for flexibility, too. “We hear over and over again from systems right now that healthcare environments have to be flexible, more so than ever—not only flexible for technology and equipment but the layout, the actual physical space,” Seely says. Considering the speed at which healthcare is changing, the urgent care of today could be just about anything else down the road, so design considerations might include installing reconfigurable casework or demountable walls all the way to building to higher standards to allow adaptation to a freestanding ED or even a hospital in years to come.
An uncertain future
Seely doesn’t anticipate urgent care slowing down anytime soon, either, with plenty still on the books for strip malls and retail locations in urban locales where real estate is at a premium. But more so, his money is on urgent care simply being a piece of an overarching strategy to bring care into communities via large-scale, branded, wellness-inspired ambulatory campuses, he says.
And while some have made more progress than others in the creation of such campuses with multiple service lines, including urgent care, many regulations are still in place that block the possibility for, say, a package of emergency, urgent, and primary care—even despite a market appetite for it.
This is largely due to the industry’s current reimbursement system paying different rates for different services, explains ESa’s Manning. “Many states and municipalities regulate care delivery so much that those trying to provide care in the most cost-effective and efficient manner may run the risk of possibly not being reimbursed at all, and many simply may not want to take that risk,” he says. “That’s the piece I find intriguing about urgent care right now. I think there’s a huge opportunity in the marketplace. Unfortunately, what we don’t have in place yet is a system to protect the people thinking about that from not getting themselves into a reimbursement problem.”
However, Manning predicts that once some reimbursement reform takes place with a focus on providing the right care at the right location, urgent care will become an even more critical piece in a patient-focused continuum of care.
Jennifer Kovacs Silvis is executive editor of Healthcare Design. She can be reached at firstname.lastname@example.org.