Ambulatory care is getting more sophisticated, and advanced healthcare services that once required hospitalization can now be delivered on an outpatient basis.
While the “bedless hospital” may exist only as a concept today, the idea of using bed counts to size up hospitals could be ready for retirement.
One notable example of this is the massive new $451 million replacement naval hospital being built at Camp Pendleton near San Diego. Scheduled to be completed next January, the 497,000-square-foot facility will house only 67 beds.
“People always ask, 'How many beds do you have?' ” Lt. Cmdr. Stephen Padhi, public works officer for the Navy, told Modern Healthcare last year. “That's an antiquated question.”
Although the bed count is low, projections call for 2,000 outpatient department visits daily.
Another project pushing outpatient care to the extreme is being built in the Bronx.
While renderings of the $142 million product clearly identify it with a sign above the door as the “Montefiore Ambulatory Care Center,” Montefiore officials are describing it as something else.
“This new tower will allow Montefiore to bring the healthcare of tomorrow to our patients here in the Bronx,” Dr. Steven Safyer, president and CEO of Montefiore Medical Center, says in a news release. “We are reshaping outpatient care and establishing leading practices that provide Montefiore's world-class treatments through multidisciplinary teams at a hospital without beds.”
Henry Chao, a principal and healthcare design director with architectural firm HOK in New York, calls a reduction in hospital bed counts “a natural evolution,” and part of the trend of focusing on continuous wellness care rather than episodic “sick care.” But he adds that there are other factors that would block healthcare from becoming an exclusively outpatient enterprise.
“What is the hospital C-suite focusing on? Flattening the cost curve,” Chao says, and that involves pushing down the high cost of episodic care in the middle while increasing resources for prevention and post-hospitalization follow-up care on either end.
Despite this focus, Chao says the nation's demographic shift to an older population will drive a continued need for episodic care, including situations such as the current influenza outbreak.
“It's not simple, it's a moving target,” he says of inpatient bed reduction. “You may have more episodic care just because people are getting older.”
Chao notes he's also working on projects in Ohio, Germany and Singapore.
The Ohio facility will have “quite a number of beds.” For the hospital in Germany, “the biggest chunk is the outpatient center.” And, at the hospital in Singapore, a new concept is being tested.
“In the old days,” Chao explains, the Singapore hospital would have been a massive 1,100-bed institution. Instead, it's being broken into a 700-bed hospital for the most-acute care with an accompanying 400-bed “step-down” hospital where patients can be transferred if they still need care after their conditions have stabilized.
Chao says that instead of a “hospital without beds,” the Ng Teng Fong General Hospital's smaller Jurong Community Hospital is being referred to as a “hospital without walls” because of the efforts to integrate it into the local environment. The facility is being built by Singapore's Jurong Health Services.
Montefiore is working with New York-based Simone Development Cos. to build its 11-story facility at the Hutchinson Metro Center, a 42-acre office campus.
Dr. Andrew Racine, Montefiore's senior vice president and chief medical officer, says the new facility represents the general direction that medical care is moving in, explaining how hospital-level, high-tech care will be delivered in an ambulatory setting and “organized thematically.”
In the new facility, lower floors will house diagnostic imaging services. Above those will be two floors for surgical services that will include operating and procedure rooms. Higher floors will be dedicated to primary care; gastrointestinal care and urology; cardiology; otolaryngology; cosmetic surgery and dermatology; and a pain center floor with anesthesiology, physical rehabilitation, neurology and a headache clinic.
The idea is to have patient-centered care, Racine says, “rather than cater to silo-driven care.” “I expect you're going to see more of these types of facilities,” he says. “We like to think this is going to be a vanguard of this type of work.”
Two drivers of this, Racine says, are the desire to avoid the high-fixed costs of hospitalization while improving the experience for patients who, after a procedure, would prefer to go home and “sleep in their own bed.”
As healthcare reform plays out, finding a replacement for bed counts as a way to gauge a hospital's size and scope of activities appears to be another task to add to healthcare executives' to-do lists.
“It depends on what you're interested in learning about the enterprise,” Racine says. He explains that square footage remains the basic measure for those interested in size, while the number of patients and patient visits could help in sizing up services.
“Maybe patient encounter is the yardstick to use,” Chao says, though he adds even that could be confusing.
During one visit, a patient might squeeze in encounters with medical, surgical and diagnostic imaging staff, as well as with a nutritionist and a dentist. So this one patient might generate five encounters while never using a bed.
“There are multiple aspects of looking at this,” he says.