Emerging Outpatient Concepts— What Healthcare Design Leaders Should Keep an Eye On

2. Emerging Outpatient Concepts—What Healthcare Design Leaders Should Keep an Eye On Post-Discharge Clinics and AYA Cancer Centers November 15, 2015 Natalie Abell, Senior Associate, ECRI Institute

3. Post-Discharge Clinics and AYA Cancer Centers Two new specialty outpatient concepts from ECRI Institute's 2015 TOP 10 Hospital C-Suite Watch List

4. Examine the parameters of new outpatient concepts and their potential impact on clinical design Discuss how these concepts can improve patient care and influence design decisions Obtain best practices for implementation, including clinical and support spaces Understand how post-discharge clinics and AYA Centers affect design cost and how to prepare for the construction

5. ECRI Institute An independent nonprofit that researches the best approaches to improving patient care New York Times called us “the country’s most-respected laboratory for testing medical products.”

6. HISTORY OF ECRI INSTITUTE’S TOP 10 HOSPITAL C-SUITE WATCH LIST • Fifth annual edition • ECRI experts polled for topics regarding…. • Something newsworthy • The potential to positively affect patient • outcomes in major illnesses, diseases, or injuries • Ready or near ready for implementation   • Turf wars or, conversely, improved collaboration • Improving patient and staff safety • A marketplace differentiator • Vote on nominated topics

7. ECRI INSTITUTE’S 2015 TOP 10 HOSPITAL C-SUITE WATCH LIST • 1. Disinfection Robots • 2. 3-D Printing in Healthcare • 3. Middleware • 4. Hospital Post-Discharge Clinics • 5. Google Glass • 6. Anti-Obesity Devices • 7. Adolescent and Young Adult (AYA) Cancer Centers • 8. Fecal Microbiota Therapy • 9. Artificial Pancreas Device Systems • 10. Telehealth

8. Hospital Post-Discharge Clinics

9. Hospital Post-Discharge Clinics • THE NEED: PATIENTS ARE VULNERABLE AT TIME OF DISCHARGE • Discharge instructions overwhelming • to many patients • 80% of discharge teaching is forgotten • by patients by the time they hit the • parking lot

10. Hospital Post-Discharge Clinics • THE NEED: PATIENTS ARE VULNERABLE AT TIME OF DISCHARGE • Difficulty scheduling timely follow-up appointments to primary care or referred physicians • -- Recommended timeframe for post-discharge follow-up varies • 48 to 72 hours after discharge (cardiac patients), 14 days for others • -- Dartmouth Atlas Project: only 42% of hospitalized Medicare patients see PCP within 14 days of discharge • -- 1 in 10 patients reported difficulty accessing PCP (lack of afterhours care, transportation, long travel times)

11. Hospital Post-Discharge Clinics • THE NEED: PATIENTS ARE VULNERABLE AT TIME OF DISCHARGE • Many patients do not have established relationships with a PCP • Hospital discharge information not communicated to PCP • Test results not forwarded, leaving the patient susceptible to unresolved medical issues • Medication prescriptions miscommunicated and difficulty filling prescriptions • -- Not uncommon for patients to have 20 or more prescriptions • -- PDC patients on 12 medications

12. Hospital Post-Discharge Clinics • THE NEED: NEW LEGISLATION • Centers for Medicare & Medicaid Services (CMS) reduces payments to hospitals with “excess” readmissions • -- Readmissions cost Medicare more than $17 billion annually • --Hospital Readmissions Reduction Program (HRRP) • -- Defined readmission as an admission to a hospital within 30 days of a discharge from the same or another hospital • -- 1% penalty in 2013 now increased to maximum 3% in 2015

13. Hospital Post-Discharge Clinics • THE NEED: NEW LEGISLATION • Acute myocardial infarction (AMI) • Heart failure (HF) • Pneumonia (PN) • Chronic obstructive pulmonary disease (COPD) • Total hip arthroplasty (THA) and total knee arthroplasty (TKA) • Coronary artery bypass graft (CABG) surgery (coming in 2017)

14. Hospital Post-Discharge Clinics • WHAT ARE THEY • Clinics that use hospitalists and nurse practitioners to bridge hospital care and needed follow-up care • Includes comprehensive discharge planning process and follow up to reduce avoidable readmissions • Also known as Transitional Care Clinics or After-Care Clinics

15. Hospital Post-Discharge Clinics • WHAT ARE THEY • Extensive time is spent on patient education • -- self-diagnosis and personal health promotion • Medications are reconciled, reviewed, and prescriptions are refilled • Patients are assessed for any new • symptoms • Pending test results are discussed

16. Hospital Post-Discharge Clinics • WHAT ARE THEY • Referral appointments are made with PCP or specialist • Case management, insurance status, and durable medical equipment needs are addressed • Clinical staff may also establish home health or skilled nursing facility care • Social environment and other non-medical issues that might cause readmissions • Everything is documented in EMR and sent to the PCP

17. Hospital Post-Discharge Clinics • GOALS • Reduce avoidable readmissions, associated costs, and penalties • Create smoother care transitions • Reconcile medications prescribed, review tests, and schedule follow-up, if needed • Reduce health disparities by increasing access to care in health-disparate populations

18. Hospital Post-Discharge Clinics • EVIDENCE • Very little clinical evidence has been published on whether post-discharge clinics lead to lower hospital readmission rates or provide a return on investment • Potential to shorten time to first visit after hospitalization • Used for vulnerable subgroups of patients for whom access tends to be most fragmented • -- majority of patients did not have a primary care provider (88%) or access to health coverage (79%).

19. Hospital Post-Discharge Clinics • EVIDENCE • Denver VA Hospital post-discharge clinic reported shorter stays with equivalent outcomes at 30 days to follow-up in primary care • Tallahassee Memorial Hospital saw ER visits and readmissions for uninsured patients drop 68 percent, thanks to its after-care facility • University of North Carolina Hospitals found their PDC reduced readmission rates within 30 days by 65%

20. Hospital Post-Discharge Clinics • RECOMMENDATIONS • To determine need for such a clinic, hospitals should first assess compliance with CMS requirements and identify deficits • Do they have readmission penalties? Evaluate the issues causing serious readmission penalties • Identify patients admitted for clinical conditions who correlate with higher readmission rates • Design and implement a screening process to identify patients unable to self-manage their post-discharge care plan

21. Hospital Post-Discharge Clinics • DESIGN • Located on or near the hospital campus • -- Hospitalist staffed • Ambulatory Care Centers or General Medical Clinics • Access to imaging, lab, social services, and pharmacy • -- integral part of delivering a continuum of care • -- provide care to patients in a one-stop shopping area

22. Hospital Post-Discharge Clinics • DESIGN • Patient-centric primary care clinic • Space for support services generally not available in primary care clinics • -- Social work • -- Addiction and chronic pain services • -- Continuity with inpatient care and subspecialists

23. Hospital Post-Discharge Clinics • DESIGN • General medical Exam Rooms and Consultation Rooms • Focus is on patient education • Consultative zone

24. Hospital Post-Discharge Clinics • COSTS • Costs to establish and maintain vary based on the hospital’s needs, patient load, and available resources • Space and a dedicated support staff are needed for an effective operation • -- cost of constructing or updating space for the clinic • Clinic generates revenue for the parent hospital through billing for patient visits • -- revenue is less important than the costs saved by avoiding readmissions

25. Hospital Post-Discharge Clinics • EXAMPLES • Bridge Clinic of San Francisco General Hospital, CA • Beth Israel Deaconess Medical Center, Boston, MA • Harborview Medical Center, Seattle, WA • Tallahassee Memorial Hospital, FL • JPS Health Network, Ft. Worth, TX • Denver VA Medical Center, CO • Metropolitan Hospital Center, New York, NY • University of Florida, Shands Hospital CareOne, Gainesville, FL • University of North Carolina, Hospitals Internal Medicine Clinic Post-discharge Program, Chapel Hill, NC

26. Adolescent and Young Adult (AYA) Cancer Centers

27. Adolescent and Young Adult (AYA) Cancer Centers WayOnHigh's channel. WHO Cares: “Teen Cancer America. Text WHO to 20222 to donate $5”. YouTube. YouTube, Apr 16, 2015. Web. 10 November 2015.

28. Adolescent and Young Adult (AYA) Cancer Centers • AYAs: Individuals aged 15 to 39 years with a diagnosis of cancer • THE NEED • About 70,000 AYAs get a cancer diagnosis each year in the U.S. • AYA survival rates worse • than other age groups

29. Adolescent and Young Adult (AYA) Cancer Centers • THE NEED • The survival rate for AYAs has seen little improvement over the past three decades • The types of cancers that affect AYAs are different than the pediatric and older populations • Most common cancers by sex:

30. Adolescent and Young Adult (AYA) Cancer Centers • THE NEED • Standard care settings do not address AYA needs, such as: • Ongoing education • Developing careers and relationships • Emotional and financial vulnerability • Fertility, family planning, and pregnancy • More patients needed in clinical trials on AYA common cancers to learn what yields best outcomes in AYAs

31. Adolescent and Young Adult (AYA) Cancer Centers • WHAT ARE THEY • Cancer centers with specialized programs, services, and built environment for AYAs with cancer (outpatient and inpatient service) • Clinical staff with expertise in AYA common cancers • Social areas where AYAs can rest, socialize, study, eat, etc. • Additional space designated for staff offices and consultations • Flexible appointment times (nights and weekends)

32. Adolescent and Young Adult (AYA) Cancer Centers • WHAT ARE THEY • Cancer centers with active clinical trial recruitment initiatives • Psychotherapy support • Explicit support for AYA future fertility issues • Service and support for other age-related issues • -- insurance/financial issues • -- high school/college • -- child care

33. Adolescent and Young Adult (AYA) Cancer Centers • GOALS • Improve AYA patient outcomes • Make AYA centers accessible nationwide • Train clinical staff and develop educational materials aimed at AYA needs • Promote investment in AYA clinical research and enroll more patients in the clinical trial process • Facilitate collaboration among AYA cancer centers

34. Adolescent and Young Adult (AYA) Cancer Centers • RECOMMENDATIONS • Cancer centers may develop their own programs or follow models set by various AYA organizations • -- One model was developed by the Teen Center America, a nonprofit organization • -- Established in 2011 as the U.S. extension of Teenage Cancer Trust • -- Organizations that form partnerships with hospitals and cancer centers to design and implement AYA cancer units

35. Adolescent and Young Adult (AYA) Cancer Centers • RECOMMENDATIONS • Health systems should determine if they serve a significant number of AYA cancer patients • Identify and access availability of existing AYA cancer services in the area, and the model(s) being used • Determine whether they would need to build new infrastructure or renovate existing infrastructure to suit the specific needs of the program • Research and review existing models to see what might be appropriate to adapt or modify to provide AYA cancer care

36. Adolescent and Young Adult (AYA) Cancer Centers • DESIGN • Units have zones for social activity and utility that surround a centrally located nurses’ station to create a patient-focused environment that maintains clinical functionality • Noisier areas such as kitchen, dining, and lounge spaces are separated from treatment rooms and doctors’ offices • Home-like environment and tailored construction to conceal medical equipment • Areas where patients require constant monitoring are oriented closest to the nurses’ stations with remote monitoring zones located on the unit’s periphery.

37. Adolescent and Young Adult (AYA) Cancer Centers • DESIGN • Individual rooms and common areas are outfitted with personal computers, gaming systems, televisions • Social areas • -- Therapy room • -- Television lounge • -- Kitchen and dining area • -- Recreational spaces • -- Classrooms for school programs • -- Units that cater to young adults may also include daycare service

38. Adolescent and Young Adult (AYA) Cancer Centers • DESIGN • Utility areas include chemotherapy preparation rooms, equipment and supply rooms • Additional space is designated for consultations, doctor and staff offices

39. Adolescent and Young Adult (AYA) Cancer Centers • COSTS • Charitable organizations (Teen Cancer America and LiveStrong) sometimes assume fundraising and financial responsibilities for building and operating • It can cost an estimated $3 million to $5 million for hospitals or cancer centers to establish and outfit an AYA unit

40. Adolescent and Young Adult (AYA) Cancer Centers • EXAMPLES • Children’s Hospital of Philadelphia • Cleveland Clinic Children’s Hospital • Hyundai Cancer Institute at the Children’s Hospital of Orange County, Orange • Knight Cancer Institute of Oregon Health & Science University, Portland • Moffitt Cancer Center & Research Institute, Tampa • Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago • Roswell Park Cancer Institute, Buffalo • Seattle Children’s Hospital • The University of Chicago Medicine • The University of Texas MD Anderson Cancer Center, Houston • UCLA Daltrey/Townshend Teen & Young Adult Cancer Program, Santa Monica • USC Norris Comprehensive Cancer Center, Los Angeles

41. Natalie Abell, Senior Associate, ECRI Institute nabell@ecri.org 610-825-6000 x5301