COVID-19 + AMBULATORY SETTINGS
By George J. Kimmerle, PhD, AIA, PP, NCARB
Transitions in healthcare planning have been going on for some time and these trends have only been exacerbated by the recent pandemic, where ICU and single room conversions and treatment settings were strained to the breaking point. A renewed focus on ambulatory heath centers as an alternative treatment setting is one clear outcome. Many of these trends were ongoing pre passage of the Affordable Care Act but have been urged forward in the form of changing medical reimbursement metrics impacting the entire medical community and spawned by the passage of that bill.
Ambulatory care is an expanding component of health care delivery
The allocation and redefinition of what constitutes ambulatory services and procedures is a function of not only technology, but also training, as more paraprofessionals are upgraded to perform relatively sophisticated procedures in a non-hospital setting. The public’s willingness to accept non-acute settings for procedures that in previous eras would have required hospital admissions is also a factor. The range of procedures include same-day surgeries to advanced diagnostic procedures, such as colonoscopies, upper GI endoscopy to radiologic and cancer care/infusion treatments.
Alternate diagnostic settings and their underlying and related causes.
Other impacts and innovations born of the pandemic include extended use of telehealth and other remote systems to mitigate in office/onsite personal appointments. However, telehealth was first instituted pre pandemic with the intent of capturing the then-documented low volume of medical use by Millennials and Gen Z. It was then feared that by deferring regular healthcare needs and potentially exposing themselves to long undiagnosed ailments, simply due to the lack of frequent medical contract, that a catastrophic future need would result for these generations, second only in size to the 1950-60’s Baby boomers. This latent health care need is now seen as the tsunami about to descend on health care systems across the board as these undiagnosed conditions emerge in later life for these populations.
A 2016 pre-pandemic survey showed that 28% of Millennials did not have a primary doctor, and that 70% had minimal medical contact (1). On the positive side it also stated that Millennials were three times more likely to embrace remote access than prior generations and that prediction has been borne out by the impact of the pandemic and surveys taken as late as Sept 2020.
All of this is impacting not only the design and layout of medical offices, but in particular the physical layout of waiting and reception areas where drop-in computer and registration kiosks are now a common and regular component of these areas. Will telehealth ultimately result in a downsizing of onsite demand, perhaps for routine and preliminary examinations? However, another outcome can lead to more pre-diagnosed and formerly undisclosed conditions whose treatment may offset the presumed reduction in in-person volume, just as the earlier pre-covid studies predicted.
On campus impacts lean towards ambulatory care as well
The pandemic has as well impacted medical planning in inpatient/main frame environments. Starting first with on-campus conversions, we are engaged with major medical institutions for on-campus ambulatory facilities that range from full building conversions and re use to new and significantly scaled medical office facilities that include areas of specialty practice and otherwise referred to as Centers of Excellence. These facilities provide an alternative setting and defer admissions, as well as lighten the load on specialty operatories and treatment areas on campus. They also provide a branding and marketing advantage, while they highlight areas of hospital specialty such as cardiac, cancer, respiratory, stoke and other modalities and treatment areas.
We are also at the first stages of a major regional master plan for a new health campus and hospital-ground up, where ambulatory settings play a huge role in the overall sizing of the inpatient requirements for this 350-bed specialty facility, expandable to over 525 beds.
The development of a master plan for a ground up health campus is a unique opportunity and one that requires an understanding of the full range of needs and the contemporary and strategic objectives of health care institution now and beyond towards a 30–40-year window. An emphasis of trends impacting health deliver and the full range of transitions in play becomes a serious point of inquiry. This new campus setting will address over 2.0 mil sq feet of healthcare space including all of the following: Inpatient/mainframe; ambulatory/outpatient services; branded practice units; cancer, cardiac, neuro and other specialty treatment centers; wellness and rehab; as well as associated extended stay lodging, assisted living and skilled nursing adjuncts.
A faster paced health care delivery model underlies all of these transitions.
A larger focus on “through put” is enabled by moving most of these less intensive medical procedures towards an ambulatory vs. an inpatient setting. All of that being said the evaluation of what procedures can transition to ambulatory settings is ongoing and being aggressively pursued.
The integration of these varied components requires a global analysis of the needs of these related facilities in any campus plan. Parking infrastructure, plant and power, etc., are all premised on the accumulated demands of the whole and their conflicting and simultaneous needs are all tested and evaluated to determine the ultimate requirements for the site. This includes the demands for an expanded ambulatory care presence which is by its nature automobile and transit dependent because of the expectation that the number and vol. of medical visits, procedures and therapies will be increased.
Ambulatory settings on and off campus
On the outpatient side we are immersed in significant re castings of in place and new medical office settings to a more advanced stage of technology and use. Advances in medical technology are occurring monthly and a facilities ability to adapt and to accommodate these advanced diagnostic and therapeutic modalities is key to its continuing effectiveness and relevance.
On the both the inpatient and outpatient side this implies core facilities that include electric generator back up, as well as other enhancements to allow for continued use in times of need. Urgent care facilities of significant scale provide alternatives to emergency department/ED visits, and many operate at extended hours and schedules. Ancillary facilities including pharmacy, blood labs and other diagnostic areas including vascular centers, radiology and imagining centers (CT scans, breast imaging, etc.) are more and more a part of the mix.
One positive outcome of Obama Care is the fact that services to the uninsured /indigent population have been positively impacted. The inundation of emergency departments to address this prior unmet need has been relieved by the passage of the affordable care act. However, the emergence of both telehealth and urgent care centers has added a new component to the whole and is now focused on the needs of another segment, the Millennial and Gen Z populations, whose lack of attention to routine care was addressed earlier in this article.
The demands for healthcare access in marginalized communities is becoming a larger focus.
We would be remiss if we did not mention the impacts of the “Black lives matter” movement which has occurred simultaneously and of late along with the COVID crisis. A renewed focus and emphasis on the needs of minority communities is one outcome and for us this includes a special focus on the health care disparities that exist in urban settings.
We are teamed now with a significant scaled faith-based organization in the CBD of Newark NJ in the development of a family health facility in excess of 95,000 sf which will occur on a consolidated campus that includes day care, early childhood/pre-K, and housing for both families and at-risk populations in a safe, consolidated, and integrated lifestyle setting. Our work with this organization actually dates back to 2017 pre covid and pre-BLM. Our interest in issues impacting marginalized populations has been ongoing and is a traditional point of interest and commitment for our firm.
This facility is programmed for family health needs and will include over three dozen specialty practice areas from OB/Gyn, to pediatrics, to allergy, asthma and a range of services focused on senior and aging care. This one-stop shop enhanced medical office environment is destined to become a national model not only for inner city health but for rural communities which are experiencing the same lack of services in the area of health.
Community survey on a national basis emphasizes their healthcare needs.
Finally, on the research / academic side we are focused at determining the ongoing trends and needs emerging in our communities. To that end our affiliated entity, the Community Design Workshop of Eastern CT, is conducting a nationwide survey of over 1400 mayors that includes the health care needs of communities across the country and dissects these results on the basis of community scale/population and regional location. This survey among other subjects’ asks a basic question regarding healthcare needs in those communities and whether current infrastructure dollars recently voted in congress should be invested there as opposed to a list of over 14 other areas of need listed in the federal bill.
Responding to ongoing trends and transitions is the underlying imperative for the healthcare industry
New paradigms are emerging daily and our ability to understand and integrate these new and cutting-edge trends and emerging modalities into our ongoing health work is a key component of our practice model. The ability to focus and innovate in these new areas of deployment in healthcare settings is key to our effectiveness and a role we take seriously in all of our commitments to health as a practice area for the firm.
George J. Kimmerle, Ph.D., PP, AIA, NCARB, is founding president and partner of Kimmerle Group.