Who needs beds? New ambulatory centers offer everything except inpatient care

If a child were to build a hospital out of Legos it might look like the new Children's Hospital of Michigan Specialty Center, an irregularly shaped, multicolored facility slated to open in February in the Detroit suburb of Troy, Mich.

“Everybody drives by it and says, 'I know that's for kids, but I'm not sure what it is,'” said Ron Henry, chief facilities engineering and construction officer at Tenet Healthcare's Detroit Medical Center, which is building the facility.

The look is appropriate because the facility is indeed for children. But the Lego analogy—building in pieces with the ability to easily convert the structure into something else—is apt for another reason.

DMC is one of a growing number of healthcare providers designing and building facilities that offer a wide range of hospital-type services without inpatient beds. The 63,000-square-foot, $44 million pediatric outpatient center in Troy will have a 24-hour pediatric emergency room, operating rooms for a range of pediatric surgeries, and outpatient care in several specialties, including cardiology, neurology and oncology.

“The building has everything you would imagine in a hospital—without inpatient beds,” Henry said.

Similarly, Montefiore Medical Center in New York opened a “bedless hospital” last year in the Bronx. The $152 million, 12-floor, 280,000-square-foot tower features 12 operating rooms, exam rooms, a headache clinic, imaging facilities and, eventually, a full-service pharmacy—but no inpatient beds.

These facilities offer a mix of telemedicine, imaging, short-term observation care and surgery. Technology allows patients to avoid being kept overnight for monitoring. Many routine checks can be done through remote digital technology. “You can set a patient up with an iPad at home,” said Erin Nelson, a consultant with Chicago-based real estate adviser CBRE Healthcare. “They can access discharge instructions, information on medication and video chat with a nurse.”

“There are way fewer big projects and more highly focused smaller facilities,” said Paul Strohm, director of global healthcare practice at design and architecture firm HOK. “We're designing facilities that are smaller and more efficient and more flexible.”

“In 1952, when I was born, everybody went to the hospital for everything,” said John Kouletsis, vice president of facilities planning and design for Kaiser Permanente. “We're saying, 'Can we actually not send people to the hospital?' Increasingly because of technology, the answer is 'yeah.' ”

The technology allows Kaiser to give patients what they want—to be able to get most of their care at smaller facilities closer to where they live and work. “A big chunk of this might be virtual care,” Kouletsis said. “As a patient, if I can do a lot of this on my cellphone, I'm totally happy.”

Some provider systems are even moving post-treatment observation and recovery out of their ambulatory facilities. Also, these facilities don't necessarily need physicians on-site to read diagnostic imaging tests since doctors can do that from another location. “In a remote area, it's a lot easier to put in IT cable than to hire another neurologist,” said Curtis Skolnick, managing director of CBRE Healthcare.

One of the big drivers of the trend toward bedless hospitals is cost. Under pressure from insurers and consumers, hospital systems have been shifting to lower-cost outpatient care, from which they generally earn higher margins than inpatient care. But a lot of this also is driven by consumer demand and the evolution of technology.

Many health systems are forgoing traditional hospital expansions and building free-standing emergency centers away from main hospitals. Last year, for example, Mercy Health system opened a stand-alone ER in Bella Vista, Ark., the first in the region. Another hospital system, also named Mercy, which operates in northwest Ohio and southeast Michigan, opened a free-standing ER in Perrysburg, Ohio. It has short-term observation beds, but sends patients needing inpatient care to a full-service hospital.

Systems also are building suburban clinics and offices for surgery or imaging rather than expanding those capabilities in centralized hospital campuses. These facilities often are designed to maximize the use of telemedicine. CBRE Healthcare's Skolnick cited an East Coast client that specifically designed an outpatient center to be able to connect doctors digitally with the main hospital in a nearby big city. “They developed an entire room where the specialists could consult with downtown, and it's all happening in real time,” he said.

As with DMC's new pediatric bedless hospital in Troy, these new facilities can be rearranged or expanded as the healthcare needs of the community and the business goals of the company change. “This building is definitely designed for future expansion,” Henry said. It's now made up of modules designed for specific types of care that can be easily converted.

Even with the suburban facility, the DMC will continue to offer inpatient care for children. It's expanding in the city also, having broken ground in August on a $140 million medical tower that will house expanded pediatric and neonatal intensive-care units, surgical facilities and exam space, and 87 private rooms. “Those needs aren't going away,” said Joe Mullany, the medical center's CEO.

But the more patients who can get care without a long trip to an intimidating hospital, the better, particularly for children, said DMC's Henry. Making a big production out of treatment, including making a long trip, can heighten anxiety.

These insights flow out of the patient-centered process by which this and other new healthcare facilities are being designed. DMC invited pediatric patients and their families to participate with doctors, nurses and other medical staff in designing the midtown Detroit medical tower. The designers created a big mockup of each floor at an ice rink to test how the users would respond to the design.

A big part of improving the patient experience is reducing waiting time. Too many patients scheduled for minor procedures have to wait as more serious cases go longer than expected. Wait times build, and patient satisfaction drops.

The new Montefiore facility in New York takes many of the more routine surgeries out of the system's acute-care facilities, producing fewer delays, said Susan Solometo, Montefiore's vice president of clinical services at the surgery-care center. “You don't want to have a healthy person that needs a small procedure next to a person who needs major neurosurgery. If you're following one of those big cases, chances are that case might run over.”

That efficiency, combined with not keeping patients overnight, is appreciated by consumers, Solometo said. “Patients come in, they're greeted—we try to have more hotel-like amenities—then they're taken care of and discharged to their home,” she said. “Our patients love the experience and our surgeons love the experience.”

Solometo said health systems have to appeal to consumers with more retail-oriented, patient-centered design features. Thinking through ease of navigation is critical in design. Simply getting smaller, however, may not be the best option, because patients don't want to have to go to multiple places to get care.

At Montefiore, designers addressed that issue by grouping specialties on floors. So rather than putting all surgeries in the same place, cardiac surgery, cardiology and vascular surgery are on one floor while plastic surgery and dermatology are another floor. But all are in the same building.

The trend toward bedless hospitals is expected to continue with the growing focus on population health management and reducing medical cost growth. “The acute setting is never going to go away, but ultimately where we're going is a population model such that they don't need the hospital as much,” said Richard Taylor, managing director of the Healthcare Solutions group at real estate firm Jones Lang LaSalle.

Skolnick said that if patients can be treated in a nearby ambulatory center and sent home to recover, they would much prefer that—as long as they know the facility is equipped to safely provide the care they need. “One primary entrance, easy to navigate, easy in and out,” Skolnick said. “Not these huge monuments.”

—David Royse is a freelance writer based in Chicago.