Tag Archive for: microhospitals

ECRI Institute has revealed its annual “Top 10 Hospital C-Suite Watch List,” which seeks to provide healthcare leaders with information on emerging innovations.
Here are the ideas, technologies and devices that made this year’s report.
An app for addiction. Pear Therapeutics’ FDA-approved reSET app topped the list. Intended to be used with outpatient therapy, it’s aimed at treating substance use disorders spanning alcohol, cocaine, marijuana and stimulants.
Direct-to-consumer genetic testing. DTC genetic tests will have an impact on how hospitals and health systems interact with patients. But as the report notes, “the exact role of DTC genetic tests in healthcare is still evolving and may vary by the information that individual tests collect.”
Acuity-adaptable rooms. As healthcare becomes more and more patient-centric, hospitals have been experimenting with a model in which they keep a patient in the same room from admission to discharge, no matter their acuity level. Challenges of this model include staffing and workflow issues.
An insertable cardiac monitor. Abbott Laboratories’ Confirm Rx Insertable Cardiac Monitor is an implantable cardiac monitor. It connects to a patient’s smartphone via Bluetooth and transmits information to the physician.
VR for pediatric patients. Numerous companies and hospitals have been developing virtual reality software to help kids be comforted in healthcare-related situations, such as repeated needle injections. However, experts have cautioned against overhyping the capabilities of VR.
A non-invasive device for treating Alzheimer’s. Neuronix’s NeuroAD Therapy System reportedly combines non-invasive transcranial magnetic stimulation with computer-based cognitive training to treat Alzheimer’s disease. It is CE-marked in Europe, but has not received FDA approval.
A device that reportedly makes blood draws less painful. Seventh Sense Biosystems created the TAP microneedle blood collection device. Cleared by the FDA, it adheres to a patient’s skin and uses 30 microneedles and a vacuum to collect blood. Seventh Sense claims the process is “nearly painless.” The downside is that blood samples currently have to be tested within six hours of collection.
A neonatal MRI system. The FDA-cleared Embrace Neonatal MRI System is for imaging of the neonatal brain and head. One limitation of the device is contraindications for babies that weigh more than 9.9 pounds or have a head circumference greater than 15 inches.
Radiation therapy for fighting brain tumors. GT Medical Technologies’ GammaTile Radiation Therapy System is “an investigational approach intended to enable intraoperatively delivered brachytherapy for brain tumors that standardizes seed placement, improves dose targeting and delivery and decreases the risk of seek migration.” It has not yet received FDA approval.
Microhospitals. In an effort to meet needs in fast-growing areas, some health systems are experimenting with the idea of microhospitals, which typically include 15,000 to 25,000 square feet of space. Usually, the scalable structures provide surgery, pharmacy, imaging, diagnostic services and occasionally labor and delivery.
Source: MedCity News

Despite their small physical size, microhospitals are fast becoming a big thing in health care design.
Historically, hospital construction has been based on the premise of “build it and they will come,” says David Argueta, president and CEO of CHI St. Luke’s Health — The Woodlands, Lakeside and Springwoods Village hospitals. Inpatient beds have in large part defined a hospital or health system. “When we talk about health care systems and hospitals, part of the statistic is how many beds we have,” Argueta says.
Today, priorities are shifting toward “driving the cost of health care down and building ambulatory access points that are focused on who we serve — really focused on the patient experience and their journey through health care. Finding a way to do that in a lower-cost environment — that’s what everyone’s trying to do,” he says.
Microhospitals can be distributed throughout a region to support a network of care; they also can be designed to be scalable, to grow along with a burgeoning community. According to Argueta, microhospitals are an innovative solution to delivering hospital care where it’s needed, to meet a health care organization’s strategic goals and its mission as a care provider.

In short, efficient, well-placed microhospitals can achieve the health care trifecta of “best value, high quality, lower cost,” he says.

Convenient and Accessible

Microhospitals generally fall between 15,000 and 25,000 square feet, though they can be upward of 50,000 or 60,000 square feet in size, says Kevin Harney, principal at architecture firm ESa in Nashville, Tenn. They typically include eight to 10 inpatient beds, eight to 10 emergency department treatment bays, a small imaging and diagnostic suite and support functions like dietary services, environmental services and materials management.
These facilities perform essentially the same functions as standard-sized hospitals but are scaled to respond to the needs of lower-acuity patients, explains Rod Booze, partner in the Texas office of health care architecture firm E4H.
Besides size, the primary difference between a microhospital and a larger community or tertiary care hospital is that microhospitals do not provide services like intensive care.

“Microhospitals cater toward the noncritical patients,” Harney says. “If a patient’s going to be there more than 48 hours, the provider will transfer [him or her] to a larger hospital. They’re trying to take the less-acute patient who needs a hospital stay and needs to be cared for but who doesn’t need to go to the larger tertiary hospital.”

PhiloWilke Partnership in Houston has designed approximately 25 microhospital facilities in the last eight years, with 20 more on the books, according to Kevin TenBrook, a partner at the firm. “It’s definitely expanding at the moment,” he says of microhospital design and construction.
TenBrook describes PhiloWilke’s typical microhospital as less than 20,000 square feet, with a full-service ED. These buildings are generally in suburban areas, 30 minutes or less from a primary hospital campus, so patients who require high-acuity care can be transferred quickly to a setting appropriate to their needs.

“The microhospitals we do are very much portal-type facilities, meaning they’re a way to get the hospital service out where the people live, out in the communities,” TenBrook explains. He adds that most projects include medical office space for physicians who practice at the hospital or are related to the health system.

Microhospitals tend to be on highly visible sites in their communities.

“From a project location or siting point of view, these are retail facilities,” TenBrook says. “One of our clients once said, ‘We expect a typical future patient to have driven by one of our facilities 100 times before they walk in the door.’”

With microhospitals, providers are “trying to create something convenient and accessible,” Harney adds.

Scalable Design

Springwoods Village Hospital is a microhospital designed by ESa for CHI St. Luke’s as part of the new Springwoods Village master-planned community in Spring, Texas, within the extraterritorial jurisdiction of Houston. The facility comprises 50,000 square feet of hospital space and 100,000 square feet of medical office space.

“It becomes almost a one-stop shop for health care, when you think of primary care and multispecialty groups and dentistry alongside our hospital services. That’s what we were trying to create,” says Argueta.

The hospital portion of the facility includes four inpatient beds, four operating rooms, two endoscopy suites with associated preoperative staging and post-anesthesia care areas, a full diagnostic imaging suite with computed tomography, radiology, magnetic resonance imaging and nuclear medicine capabilities, and a 10-bed ED.
The microhospital, on a 26-acre site, is master-planned to expand over time into a 200- to 300-bed tertiary care hospital. The scalable design is meant to serve the immediate and long-term needs of the community, Argueta says. By starting with a microhospital, “you’re able to grow intelligently. You don’t have 100 or 200 beds to start out with. You may have four to 12 beds and concentrate on more procedural areas,” he says.
This type of phased development makes efficient use of resources and gives local residents the comfort and convenience of having access to both nearby health care services and a larger network of care, he notes.
Argueta explains that CHI St. Luke’s, which historically has been inpatient-focused, recently has concentrated on developing facilities to serve patients along the entire continuum of care. The health system now has nearly 50 access points and almost 100 physicians in the North Houston area.

“We consider [Springwoods Village Hospital] a part of the continuum,” he says. While the microhospital can handle most patient needs, The Woodlands Hospital, CHI St. Luke’s flagship facility in North Houston, is a comprehensive stroke center that can provide higher-acuity care for patients who require it. The health system’s facilities are complementary, Argueta says.

Neighborhood Hospitals

Dignity Health–St. Rose Dominican health system has been working with Houston-based microhospital developer Emerus and other partners to implement a microhospital strategy in Las Vegas. The health system has opened three microhospitals so far this year, and another is in the works.
The first floor of each Dignity Health–St. Rose Dominican microhospital, designed by PhiloWilke, includes eight inpatient beds and a similar number of emergency treatment and triage rooms, along with computed tomography, laboratory, X-ray, ultrasound, pharmacy and dietary services.
“Each location has either one or two additional floors that are purposed for Dignity Health–St. Rose Dominican’s other clinical services,” says Vic Schmerbeck, executive vice president of strategy and business development for Emerus. These include primary care, wellness centers and other specialty clinical services.

The microhospitals are located on sites that range from 3 to 7 acres. “They are highly visible and accessible for patients,” Schmerbeck says. “All of them sit on hard corners in retail-centric locations, to provide great access for patient care in areas we believe have needs in the marketplace.”

“We’re calling them neighborhood hospitals. They are fully licensed, Centers for Medicare & Medicaid Services-certified facilities capable of providing a continuum of care, albeit at a lower acuity level than some of our larger, more complex facilities,” says Peggy Sanborn, vice president, partnership integration, Dignity Health. “They’re generally distributed to better serve the overall population in Las Vegas, particularly as we migrate as an organization to value-based contracts and at-risk contracts.”

Population health management was a key factor in the health system’s decision to deploy microhospitals in this manner, Sanborn says. “First of all, we’re able to provide access to care that’s most commonly accessed at hospitals, which is predominantly outpatient-oriented, through this lower-cost model. So it preserves on capital and expenses as it relates to creating access points for patients.”
Additional access points help to prevent bottlenecks to care.

“Many times in communities that are under-resourced, you have long waits for emergency services,” notes Sanborn.

The neighborhood hospitals will provide needed services and allow Dignity Health–St. Rose Dominican to keep patients in network as the health system moves forward with some of its more narrow-network or value-based population health-oriented contracts, she says.
According to Sanborn, co-locating outpatient diagnostics and physician services on the microhospital sites creates “minimedical campuses” where local residents can receive primary care, outpatient care, emergency treatment or a short-stay, acute care inpatient admission.
She says that Dignity Health–St. Rose Dominican has developed resources to transfer patients with more complex medical needs in a timely and effective manner to hospitals within the system that provide higher levels of care, and for the system’s medical staff and management team to coordinate care for patients across the entire network.

Health Care Evolution

“What we’re trying to do is evolve our health care thinking and make it much more community-facing, so that patients feel [as though] we’re delivering the product to them,” Sanborn says. “We’re starting to look at how you address the way patients want to access care.”

Millennials want convenience and immediacy in care resolution, she notes. “We want to be evolving or thinking about health care delivery in a similar way,” she says.
Microhospitals enable health care organizations to provide “great care in a patient-friendly and convenient manner, while remaining disciplined on capital and operational efficiency,” Schmerbeck adds.
Source: H&HN

Horizon City-Microhospital Rendering

Last September, The Hospitals of Providence, a leading healthcare provider in El Paso, Texas, broke ground for a new medical campus on 10 acres in suburban Horizon City, 20 miles east of El Paso. There they will build a 40,000-sf “microhospital” to house an emergency department, a laboratory, imaging services, and 10 to 12 inpatient beds. The campus will also have 50,000 sf of office space for physicians and staff.
Microhospitals are acute care facilities that are smaller than the typical acute care hospital. They leave complex surgeries to the big guys, but are larger and provide more comprehensive services than the typical urgent care or outpatient center. They range in size from 10,000 sf to 60,000 sf.
Microhospitals offer the full services of a hospital emergency department and have labs that provide rapid clinical diagnostics and x-ray, CT, and ultrasound imaging. According to healthcare consultant Advisory Board, microhospitals can meet up to 90% of the healthcare needs of the communities they serve. And they never close.
Like urgi-centers and outpatient clinics, microhospitals generally treat patients with low-acuity medical problems. Unlike urgent care and outpatient facilities, they have inpatient beds (typically anywhere from eight to 15) and can support overnight observation of patients who require low-acuity hospital services.
The Horizon City microhospital, which will employ 75 clinical and nonclinical staff when it opens in September, will fill a gap in the availability of hospital-level services for Horizon City (2013 population: 18,997), whose area population has ballooned 180% over the past 16 years. “Initially, we had planned to go with a freestanding ED with imaging functions, but we took a step back and concluded that wouldn’t be enough,” says Sally Hurt-Deitch, Hospitals of Providence’s Market CEO. Hospitals of Providence has plans to open at least two more microhospital facilities.
Microhospitals are the latest twist in “population health,” as healthcare systems search for ways to bring quality care to demographic markets that can’t support full-size hospitals and offer such care closer to where people live and work.

“The days of us building 200,000-sf hospitals are over,” proclaims Isaac Palmer, CEO of Christus Health. Next fall, Christus will open the first microhospital in Louisiana, a 10,000-sf facility in Shreveport-Bossier with six short-stay inpatient beds. “It’s kind of a souped-up doctor’s office,” says Palmer. “We’re moving toward microhospitals to enhance our integrated delivery network,” says Laura Hennum, Chief Strategy Officer at Dignity Health. “It’s all about population health and one-stop shopping for consumers.”

At the close of 2016, there were at least 50 microhospitals operating in the U.S., according to Environments for Health (E4H) Architecture, which has designed a dozen of them. Micros are particularly popular in parts of the Midwest and certain western states, notably Arizona, Colorado, Nevada, and Texas. Most of the microhospitals in operation or under construction are located in states that don’t have certificate of need programs aimed at controlling overbuilding of healthcare facilities.

“This is a new concept,” says Chris DiGiusto, Corporate Vice President of Ambulatory Services with Franciscan Alliance, Indianapolis. The 14-hospital system will break ground on a 20,000-sf, $12 million microhospital with 12 emergency exam rooms and eight inpatient beds next month. “It’s like a tiny house: the essentials and nothing else,” he says.

DiGiusto admits that competition entered into Franciscan’s decision to plug a micro into the larger $50 million medical complex it’s building. St. Vincent Health, a 20-hospital system, has announced plans to build eight microhospitals in central Indiana, each with eight beds. DiGiusto says that St. Vincent’s first micro “will be right in Franciscan’s [patient] catchment area.”
Hospital admissions have declined in recent years, as patients have chosen to patronize clinics in pharmacies, urgent care centers, freestanding outpatient facilities, ambulatory procedure operations, and independent emergency care centers. Microhospitals have become service bridges between EDs and hospitals, especially in markets that lack convenient patient access to large hospitals.

“Some clients look at micros as an alternative to investing huge amounts of money in larger healthcare facilities,” says Catherine Corbin, Principal and Chicago Health Practice Leader for CannonDesign, which has prepared a tactical report on “Microhospitals: Inpatient Services with Outpatient Convenience.” Corbin says that health systems also see micros as a way of “planting their flag in new communities” and expanding their services outside of urban areas.

Microhospitals have been around for at least a decade, but they’re starting to proliferate. They’re cheaper to build than giant regional hospitals, averaging between $7 million and $35 million in construction costs, with much shorter build times—about 12 to 14 months, according to AEC industry sources.
They can also bill patients at the same rate as acute care hospitals. Their reimbursement from private insurers and Medicare and Medicaid is generally higher than for freestanding EDs or urgent care, outpatient, and freestanding surgical centers.

“For a freestanding ED to get maximum reimbursement, it either needs to be tethered to the mother ship or it has to build its own hospital,” says Rod Booze, AIA, ACHA, NCARB, Principal, E4H Architecture.

So far, most microhospitals have been developed, constructed, and operated by third-party management companies through joint-venture agreements with health systems. They can be pretty secretive about their business models and facility designs.
Embree Asset Group, Georgetown, Texas—whose partners include Indiana’s St. Vincent Health and St. Luke’s Health System, based in Kansas City, Mo.—would not identify AEC firms it has worked with. Texas-based Adeptus Health, which reportedly operates a few micros, wasn’t available for comment.
The clear leader among microhospital management companies is Emerus Holdings, Woodlands, Texas, which was launched in 2006 by a group of emergency-care physicians. At the end of 2016 Emerus was operating 22 micros with more than 1,500 employees for various healthcare systems across the country. Emerus intends to triple its complement of facilities and systems partners and quadruple the number of states in which it operates by 2020.
Emerus’s prototype delivery model can be adapted to meet the needs of specific communities and patient demographic niches, says Dudley Carpenter, the company’s Senior Vice President of Real Estate.
Emerus prefers building from the ground up, typically on three acres; the company finds “little value” in retrofitting existing buildings, he says. The nurses’ stations have been designed to optimize sightlines and accessibility. CT and x-ray rooms emphasize patient comfort. Some of its micros have staffed surgical suites with anesthesia, post-operative care, and pain control capability.

“The bottom line comes from the square footage,” says Carpenter. “We are a hospital but it’s not a footprint with 100 or more beds. We bring that down to about 20,000 sf.” That also lessens the burden on local communities’ power and water resources, he notes.

The health systems with which Emerus partners are the “established brands” that confer legitimacy to the micros, says Carpenter. Sources at those systems respect Emerus’s track record. “Emerus is an organization that has executed microhospitals successfully,” says Hospitals of Providence’s Hurt-Deitch. “They fit our model.” She explains that micros can support the larger system without requiring the same manpower as a full-scale hospital. In some cases they can actually share staff and professionals with the acute care hospital.
Micros can also be more patient-friendly than other delivery formats. Dignity Health’s Hennum notes that the average admission-to-discharge time for all healthcare facilities in Nevada is 154 minutes; at Emerus-operated facilities, it’s less than half that: 74 minutes.
Franciscan is among the holdouts that have chosen to develop and operate microhospitals on their own. “We couldn’t get the math to work out right” by using a third-party management partner, says DiGiusto. “The margins were too thin.”
DiGiusto also wasn’t overly impressed with other micros he’s looked at. “They’re basically urgent cares open 24 hours a day with CT scanners. We didn’t think they’d meet our quality standards.”
Only a few AEC firms have engaged in microhospital projects. The Building Team on Franciscan’s complex, for example, includes Arc Design (architect and designer), KJWW (MEP), Crossroads Engineering (CE), Mader Design (landscape), and Tonn & Blank (GC).
Emerus has had a long-standing relationship with Houston-based architecture firm PhiloWilke Partnership. The first micro that PhiloWilke designed for Emerus was a retrofit and expansion of an 8,000-sf ED in a strip mall in Sugar Land, Texas. The facility had two inpatient rooms, eight exam rooms, a dietary department, and some imaging capability, all squeezed into 13,000 sf. That was a test run for Emerus’s first official microhospital, which opened in Tomball, Texas, in 2006.
After taking a timeout to refine its prototype and business model, Emerus built five micros in San Antonio in 2010, one of which was a converted 26,000-sf shoe store. Since then, PhiloWilke has developed several microhospital prototypes for Emerus, says Kevin TenBrook, AIA, LEED AP, a Partner at the design firm.
Emerus’s first-generation micros had a footprint of about 20,000 sf with a second floor (and sometimes a third) for office space. There was also a single-story model for tight plots. The second generation is three floors in a 13,000-sf footprint.

TenBrook says his firm’s microhospital designs for Emerus “have as much space for patients as full-size hospitals.” Over the years, PhiloWilke has been able to get construction costs down to 60% of the original prototype. It is now exploring what kind of micro could be built on a half acre.
PhiloWilke’s designs, says TenBrook, fall within the “spirit” of guidelines for hospitals put forth by the Facilities Guidelines Institute, the independent nonprofit that provides guidelines for the design of medical facilities. FGI does not have specific requirements for microhospitals and has yet to address differences between microhospitals and critical access hospitals, says FGI spokesperson Douglas Erickson.
While PhiloWilke has captured the lion’s share of Emerus’s design work, Emerus and its healthcare partners are drawing from a wide pool of contractors for microhospital construction. In Dallas, Baylor Health Care System favors Medco Construction. In San Antonio, Gilbane, Vaughn Construction, and F.A. Nunnelly have built or are building micros for other health systems. S.R. Construction and Martin Harris have been used in Las Vegas, Kiewit Building Group in Colorado, and Anderson Construction in Idaho.
TenBrook is convinced that Emerus has created a viable product that “makes sense from an investment point of view.” He points to Baptist Emergency Hospital’s recently opened 38,500-sf micro at Zarzamora, in South San Antonio—once a “healthcare desert,” he claims—that has been handling twice the average patient load than was originally projected. (Depending on the market, microhospitals expect to see anywhere from 30 to 100 patients a day.)
Dignity Health plans to include medical office spaces and wellness centers in its micros and is considering leasing space for physical therapy and ambulatory surgery centers, says Hennum. Dignity will measure three variables—market demand, patient experience, and clinical outcomes—to determine whether its microhospitals are working, to decide if it will build more of them. Hennum says Dignity is looking into opening micros in California.
But healthcare construction trends come and go. It wasn’t too long ago that experts thought there were no limits to the growth of medical office buildings; in many markets, MOBs now seem passé, as patients choose other types of care facilities that fit their medical needs and tight wallets better.
Then there’s the cautionary tale of Adeptus Health, the nation’s largest ED operator, which lost $11.7 million in Q3/2016 and saw its stock price plummet by 88.4% from May 16 to $7.43 on December 22. Is Adeptus’s precipitous decline a signal that its business model, which relies heavily on non-hospital-affiliated emergency departments and on charging patients “facility fees” to cover its overhead, might not be sustainable?
(Emerus Senior Vice President Jason Jisovicz says his company has avoided Adeptus’s financial problems by using in-network services.)
There’s also no consensus about how quickly or broadly microhospitals might spread. Franciscan’s board has given DiGiusto approval to explore replicating the micro model at other Franciscan facilities: “We need to take some pressure off of our hospitals, which are regularly out of beds,” he says. But he doesn’t foresee micros having anywhere near the same growth trajectory of, say, urgent care centers. “You need special circumstances,” he says, especially regarding location: Micros only work in communities that don’t have ready access to a large acute care hospital.
CannonDesign’s Corbin says interest in microhospitals could last another five years, but she also expects states to tighten their reins on what kinds of healthcare facilities they allow. She says some investors already view the investment cycle of micros as being closer to medical office buildings (10–15 years) than full-size acute care hospitals (50 years).
PhiloWilke’s TenBrook says the only thing keeping microhospitals from becoming more mainstream is state regulations that are, in his view, “out of sync with the idea of a small hospital.” To meet one state’s code, he says, his firm had to produce a design template showing four janitors’ closets in every micro, when one or two would have been more than sufficient.
E4H’s Booze says the precariousness of the Affordable Care Act, which spurred healthcare growth over the past five years, makes predicting hazardous. He says one client in the Northeast that he would not name views microhospitals as “a growth instrument in a nongrowth market.”
Booze believes that as long as healthcare providers and private developers see micros as a real estate infill play, some day there could be up to 250 microhospitals dotting America’s countryside.
Source: BDCNetwork