Upali Nanda (PI), Seluga Sekanwagi, Adeleh Nejati, Lindsay Graham, and Sipra Pati
Tom Harvey, Principal and Senior Vice President, President of CADRE, HKS Inc., Dallas, TX
Ralph Hawkins, Chairman, HKS Inc., Dallas, TX
Jim Miller, Sr. Vice President, Healthcare, JE Dunn Construction
Ron Smith, Design at the Intersection LLC
Phil Macey, National Director Collaborative Project Delivery, JE Dunn Construction
JE Dunn Construction and HKS Inc.
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WHAT WAS THE AIM
To ask the fundamental question: "How do we design, not for a faceless future, but for an ever-changing present?" To answer this question we sought to understand what are the key drivers of change in healthcare, review prevalent trends in response, assess the facility implications of these trends, identify innovations and evidence support through literature searches and case studies, and finally, via the filter of what patients and physicians want, develop a framework for a change-ready clinic.
WHY IS IT IMPORTANT
It is evident that there is a shift to outpatient care and preventive health. As such, many new trends are emerging but the evidence base remains thin. What is also not clear is whether patients really want what is being provided, are physicians on board, and are the trends we see today just a fleeting idea du jour, or are they sustainable and here to stay? Most importantly, what are the key components of a change-ready clinic that can withstand a rapidly changing healthcare ethos?
WHAT DID WE DO | HOW DID WE DO IT
To answer these questions we conducted a study in 5 parts:
A literature review to identify key drivers of the systemic change. These included:
the healthcare delivery system
the patient population
physician availability and care team configuration
field of medicine
data and technology.
A literature review to identify key trends in response to drivers, with a call out to supporting evidence and facility implications. These included:
mHealth (mobile health)
A case study to look at three clinics that exemplified three of the emerging trends (Intermountain Health, Adelante Health, and Five Forks Family Medicine)
Surveys of 150 millenials and a 150 boomers who had visited a clinic for the first time in the last 6 months
Surveys of a 100 family practice physicians / internal medicine physicians
Insights from the lit review were filtered through the case studies, and the survey findings to develop a framework for the key space types, and characteristics of a change-ready facility
WHAT DID WE FIND
At the end of the study we revisited the trends and drivers:
System: Increased Access but not Affordability: System wide there is increased access but not affordability. Patients still make their decisions first and foremost based on coverage under health plan. Physicians remain highly skeptical of healthcare reform.
Patients First: For the first time there are 4 generations in the work force, and this inter-generational need is compounded by the increase in an aging population and more complex and chronic conditions. However, contrary to the prevalent trend of thinking of patients as consumers, when asked, both millenials and boomers (more than 85%) consider themselves "patients needing health services" rather than "consumers buying health services". The patient may have higher expectations, but is still a patient first.
Team-based care: Combined with physician shortage, the need for teams is a response to complex conditions and care delivery systems. Survey findings show that there is a significant correlation between physicians who work with care teams and overall satisfaction. Also, working with care providers was found to be a predictor of physician satisfaction.
Technology utilization but not seamless integration: Although there is a big boom in both technology and big data with the rise of mobile devices, sophisticated and miniaturized diagnostics, and large reservoirs of data, physicians remain skeptical about electronic health records and report that it takes away a disproportionate amount of time from patient care.
mHealth + telehealth: A question of trust and connectivity
51% of physicians are using more than one device (laptop/phone/desktop/tablet) for patient engagement showing the increasing physician adoption of mobile technology. 54% of millenials consider their phone a life line and would like to access health services through it. Although boomers are more conventional in their use of mobile technology the younger generation consists of digital natives and more and more mobile health platforms are likely to emerge. Physicians are open to the idea of telehealth but dont believe it can replace face to face consults; the challenge according to them is trusting the accuracy of the technology, trusting patients are able to use the technology, and having the connectivity needed. That said, of all the trends physicians consider telehealth to be the most sustainable. Millenials are more ready than boomers to replace in person visits with virtual visits. Implications for facilities include tech-ready and data-integrated facilities, with provision for mobile platforms (i.e. more flexibility in both the structure and the furniture systems). It is not clear yet how the shift to more cloud -based facilities is impacting the footprint of the clinic other than having provisions for call centers and video-ready conference rooms. This is an area for exploration.
Population Health: Just getting started
Population health is considered by physicians, and leadership, to be a sustainable trend, but doesn't have systemic support (reimbursement structure, time etc.). Survey data showed that follow-up care was a top of mind concern for physicians, and predictor of patient satisfaction. At Adelante Health diabetes control was increased by using a patient centered medical home model based on a population health premise (adelante used talking rooms to encourage a larger team interaction about whole health). In general, fitness consciousness was reflected in the large percentage of patients (63%) reporting owning a fitness app on their smart phones. Population health is arguably the largest opportunity for designers today, but needs more systemic support.
Coordinated Health; Precise, personalized and managed care
Physicians consider coordinated health to be slightly more "trendy" than sustainable. In the survey responses physicians mentioned working most extensively with other physicians, medical assistants and office managers. Although a relatively low percentage of physicians worked with case managers, for those that did it was found to be a significant predictor of physician satisfaction. More and more clinics are adopting the team-care model that is reflected in open offices, team spaces, on-stage off-stage work areas, and integrated technology for care coordination. However, accommodating the components of a PCMH model remain a challenge. While personalized and managed care are gaining popularity, how clinics tie into the precise medicine initiative warrants further investigation and depends on the systemic co-dependencies between clinics and the larger health systems.
Retail Health: All about the experience, but not necessarily being a consumer
The term retail in clinics has typically been associated with clinic owned by retail giants like Walgreens and CVS. In this report we took a different approach to this trend, to include more consumer focused access points (including retail clinics, virtual clinics, concierge services, urgent care centers and multi-specialty clinics that provided a one-stop for services) and a shift to hospitality inspired elements, with a focus on convenience and enhanced ambience. However, survey data showed that when given a choice patients (both millenials and boomers) consider themselves a patient needing health services, over a consumer buying health services. "Spa-like " amenities while rated highly by millennials fall to the bottom of appealing clinic characteristics for boomers. Both boomers and millenials value having a good experience over just having their health services addressed, but defining this experience may require more inter-generational sensitivity. Physicians think of retail clinics as a passing trend, but do value patient experience as a top of mind concern.
Take Aways: Insights from the lit review were filtered through the case studies, and the survey findings to develop a framework for the key space types, and characteristics of a change-ready facility. Some key findings from the study are:
Considering the patient a “consumer” may be premature- people visiting a clinic consider themselves patients needing health services, not consumers buying health services. This is true for millennials (87%) as well as boomers (88%).
Even as a patient, experience trumps having just a health issue addressed across both age groups. For millennials, more than boomers, experience was important. However, specific enhancements like a “spa-like” experience are valued much higher for millennials (ranked fifth) compared to boomers (ranked fifteenth).
Millennials would like to use smart phones to access health services (61%) , while boomers still consider a phone just a means of communication (76%).
The facility feature that is a top of mind concern, across age groups, is cleanliness.
Telehealth is something physicians are ready for, with certain caveats. However, they don’t think patients are quite as ready. This is true for boomers, but millennials are ready for virtual visits.
Physicians who work in open offices today are more likely to prefer open offices to work.
The survey also revealed top and bottom ranking considerations for what makes a clinic appealing, and a patient likely to return. In filtering the facility innovations observed through literature searches and case studies, and through the data from surveys, 2 key space types, and 3 key space characteristics emerged.
Design Implications: Change-ready facilities were identified as having two key types of spaces: Consult space (that can foster meaningful, informed, interactions) and Work space (that support the key consult or patient/provider connection). Each traditional space can be thought of as one of these two kinds of spaces. Example, registration could be done by a Medical Assistant, making it the first consult, waiting areas could have education elements making it a virtual consult while they "pause", exam rooms are certainly becoming more "consult" areas (enabling virtual consults), and even discharge could be an opportunity for a follow-up care re-affirmation and consult. In other words, to think of all patient spaces as spaces of meaningful interaction. Workspace is all the space that is required to support this key patient-provider (diverse team based) relationship in an efficient manner that promotes wellbeing of the care team.
Three key characteristics of space were identified as: flexibility, connectivity and sense of place. Flexibility relates to the ability to expand, contract and shape-shift based on changing needs, all the way from plan and configuration to selection of wall systems and furniture. Connectivity, is a key finding of this report that relates to thinking of the clinic as a "conduit" between the cloud (systemic connectivity to health information) and community (regional connectivity to target population). Connectivity also emphasizes the need for connection to site (strategic location) and connectivity between complex teams. Finally, sense of place relates to developing a destination, an experience, that is clean, quiet, comfortable, connected and appealing across generations (though generational specificity can be targeted based on target demographic).
WHAT IS NEXT
This document is our first pulse-point research, where we take the pulse of the industry to assess our own priorities and processes. To stay relevant, this document will be treated like a living document. Each year the Clinic 20XX information will be updated. Additionally, the surveys will be continued with a larger population (already the survey has been conducted with 300 additional patients and 120 physicians in a regional health system). Finally new modules of the survey will be developed to poll staff, and other team members, to allow a comprehensive and continuing insight into clinic design.