Decentralization commonly refers to transferring control of something to multiple authorities rather than one. When we look at decentralization as it relates to healthcare, there is an interesting trend in the United States that was first seen in Europe in recent years. “Decentralization in Health Care,” a book that was first published in 2007, offers some interesting insights into themes that emerged in Europe that could be used as a roadmap for the healthcare system in the U.S. The themes include a movement focused on patient experience and a shift to outpatient care facilities to serve the whole person.

Over the last three years, we have seen a dramatic increase in new and renovated project types including ambulatory surgery centers, cancer centers, imaging centers, and, most notably, retail health. This is in response to changes in the public’s expectations of their health services providers, advancements in technology and governing bodies allowing further medical procedures in an outpatient space, as well as the opportunity outpatient facilities present to reduce carbon emissions generated by the healthcare industry.

Convenience is Breeding Change

The COVID-19 pandemic dominated the landscape of healthcare and changed how the average consumer viewed their approach to their own health care and the role the hospital played in it. Coupled with the lack of certainty related to the scope and cost of health services, consumers became more selective about the procedures they would undergo, which were primarily out of necessity. If such a procedure was capable of being performed in an ambulatory surgical center, this was preferred to avoid unforeseeable costs resulting from admission to a hospital. During this time, many patients sought primary care through clinics and urgent care facilities, as well as those with telehealth capabilities, creating a new expectation of proximity and convenience for their health care. With the adoption of these providers and avenues for health services, convenience and cost of care appear to have become the name of the game for the healthcare industry.

With these patient expectations in place, the door has opened wide to a variety of providers who can meet them while also providing consistent quality of service. Cost, convenience, and consistency of experience are key attributes of many companies offering products and services related to health and wellness as well as retailers such as pharmacies and grocery stores. These entities are leveraging their footprint, brand development, and service delivery expertise to bring convenient healthcare services to all corners of the nation. It was noted in underserved regions that retailers like Dollar General have been reaching patients whom many providers cannot, offering needed, basic healthcare services. The integration of hospitality and aesthetics to enhance the environment and promote the patient experience is also attracting patients.

This adjacency of health and retail has adjusted the role medical office buildings (MOBs) play in the healthcare space. Retail centers like malls, street fronts, and mixed-use developments are now being planned and marketed towards prospective health service tenants. These facilities often have a broad mix of tenants such as fitness centers, grocery stores, restaurants, clothing, and merchandise, offering a convenient solution for physicians to serve patient consumers as they go about their day-to-day lives.  It’s also an attractive real estate option for a physician to develop their practice on top of off-campus and on-campus MOBs. For on-campus MOBs, depending on how a healthcare system (both as a patient access and real estate entity) plays a role in a physician’s business model, this can impact the need or desire to stay on-campus as opposed to seeking alternate sites for their practice.

Guidelines are Increasingly Accommodating

With the recent shift to Inpatient and Outpatient guidelines from the Facility Guidelines Institute (FGI) care environments (Operating rooms, exam rooms, etc.) are held to a similar level of design regardless of whether the patient receives treatment at an ambulatory surgical center (ASC) or a hospital.

The 2014 edition of FGI was the first time two independent documents were published: hospitals and outpatient facilities and residential healthcare and support facilities. Starting with the 2018 edition of FGI, the publication was split into three independent documents: hospitals, outpatient facilities, and residential healthcare and support facilities. The intention of the 2018 edition could be viewed as placing patient care within outpatient spaces on equal footing with inpatient or hospital spaces.

Other major updates between the 2014 and 2018 FGI publications included:

• The introduction of sustainable design initiatives and metering.
• The expansion of accommodations for telemedicine services from one paragraph in the 2014 edition to its inclusion within the minimum guidelines and appendix guidelines. These focus on flexibility of space as well as patient privacy.

Like the 2018 edition, the 2022 edition of FGI featured three independent documents: hospitals, outpatient facilities, and residential healthcare and support facilities:

• The shift from two documents to three independent documents was a large yet intentional shift to allow for flexibility to address the growing outpatient care space types to keep up with the evolving needs of caregivers.
• Space designation terms were updated from 2018 to 2022 to add clarity and alignment between room use and space designation, which impacts the space design parameters.
• Accommodations to serve patients within rural areas with critical access hospitals, behavioral and mental health hospitals, and transportable medical units were added to offer clarity for those spaces and guidelines for design.

Another factor that can influence codes and guidelines is insurance and reimbursables. In some instances, patients can select the location where they will receive care. Services such as physical or occupational therapy may be completed inpatient or outpatient. Health insurance companies outline a summary of benefits that detail cost sharing information for these rehabilitation services and may have differing copays or coinsurance when differentiating between inpatient and outpatient treatment.

The benefit of seeking treatment at an ASC in lieu of a hospital could be the ease to get scheduled into care and a potential reduction in cost. Overall, outpatient care spaces (ASCs, MOBs, etc.) up to 23 hours of care, not full overnight care. This provides cost savings for the patient since overnight care is not offered or required and therefore support services are offered at a reduced cost. With the ease of patient experience, scheduling for services, and access, coupled with a potential reduction of overhead costs, this increases the drive of patients to outpatient care spaces.

In ASCs, procedures that don’t require admission to the hospital for monitoring or care pre or post procedure grew in popularity ahead of the pandemic, and that growth has accelerated since. Johns Hopkins Medicine identified tonsillectomies, gallbladder extractions, and several elective/cosmetic surgeries as common outpatient procedures. In addition to ASCs, imaging centers are also becoming more prevalent within outpatient care centers.

Many advancements have paved the way for the impending boom of outpatient centers. Medical equipment has become more available, improved medical practices have reduced the potential for infections acquired during a hospital stay (ventilation design, disinfection, sanitization, etc.), and patient pain management and sedation tactics have greatly improved the potential outcomes of patients seeking care.

As seen with the recent coronavirus pandemic, current events can influence changes in codes and guidelines. Since 1970, health spending has risen $12,000 per person on a per capita basis. According to the Peterson-KFF ongoing study, approximately a third of healthcare costs are hospital, a quarter of costs includes spending on health products and personal care, and the remaining costs are born from outpatient facility visits (i.e.. chiropractor, dental, prescription drugs, clinic visits, etc.).

Reducing the Healthcare Carbon Footprint in Outpatient Facilities

With increasing industry focus on sustainable and regenerative design practices, the impact of decarbonization is an important piece of decentralization. Healthcare facilities account for 10% of U.S. greenhouse gas emissions. Hospitals make up 35% of those emissions while outpatient and support services account for the rest. The greatest opportunity to decentralize healthcare starts with non-hospital facilities.

As more services leave hospitals, there is a real estate advantage to providing energy efficient, low greenhouse gas projects. Many municipalities across the country are beginning to require high efficiency practices. Several notable requirements include the Denver 2030 District, which will require buildings more than 20,000 SF be 30% energy efficient. Additionally, NYC Local Law 97  in New York City plans to reduce GHG 80% by 2050. As time goes on, it is inevitable that many more authority having jurisdictions will set forth requirements regarding electrification. Ensuring real estate holdings will be compliant with future building requirements is critical.

Outpatient facilities have more opportunity for decarbonization due to the less stringent facility requirements. Some of the reasons for this are little to no steam use, no kitchen facilities, and low humidification requirements.

Building electrification is possible and can provide a lower first cost in some new construction. Several items that can help healthcare facilities achieve electrification are:

• Removing direct emissions due to boiler/water heater venting.
• Reducing emissions associated with natural gas use. Natural gas is traditionally used for hot water, building heating, and steam for sterilization.
• Heat pump technology, which is perfect for medical office buildings, ambulatory surgical centers, and other decentralized healthcare facilities due to the less stringent temperature and humidity requirements.

It is clear the healthcare industry is changing, and it will continue to decentralize from the traditional hospital-centric model. As this shift continues, we expect healthcare providers to evolve their real estate portfolios to match the demands of patients they serve. These changes bring new challenges and opportunities that provide design teams with an opportunity to innovate and integrate modern technologies to improve how we define and experience patient care.

Henderson Knows Healthcare

Henderson has been designing healthcare projects for more than 25 years and understands that each facility, campus, and project requires a unique approach. With that great responsibility comes the need to design solutions for patient safety, complex equipment, facility infrastructure, and patient experience. Our experts are on the frontlines helping healthcare providers navigate modern technology, complicated code requirements, and the emergence of neighborhood medtail clinics – all while taking patient care and safety as seriously as our clients do. To learn more about our Health Sector, click here.

References

Centers for Medicare and Medicaid Services

Facility Guidelines Institute (FGI)

John Hopkins Medicine

Peterson-KFF Health System Tracker