by Lola Butcher

Patients like the convenience of having stand-alone emergency or urgent care centers in their neighborhoods, say providers that have opened these centers. Urgent care centers offer a second patient-friendly plus: Patients like the fees these clinics charge, which are often less than the bills they would receive after a visit to an emergency department (ED).

The patient-pleasing centers can typically handle acute and complex cases that are beyond the abilities of nurse-managed retail clinics, another popular outcrop of the consumerism movement.

But do these stand-alone centers make business sense for hospitals, health systems, and other providers? Two organizations share their stories.

Case Study 1:

WakeMed's Stand-Alone EDs Drive Business to Medical Complexes

In 2002, WakeMed Health and Hospitals built a suburban medical complex, or "healthplex," with an ambulatory surgery facility, imaging, laboratory services, and space for medical offices. But the office space did not fill as quickly as expected.

Meanwhile, patients seeking emergency care saw the WakeMed sign on the healthplex and frequently pulled off the highway in search of immediate medical attention.

So WakeMed added a stand-alone ED to the healthplex in 2005, and the after-thought project has become the driver for the medical complex's success.

"We found that, by putting an ED in the complex, we get so much more foot traffic, and people realize all the other services that we have," says Carolyn Knaup, vice president of ambulatory services at the Raleigh, N.C.-based health system. "It has become a true destination point for medical healthcare consumption."

Meeting higher-than-expected volumes. The stand-alone ED, which will see roughly 33,000 patients this year, turned profitable after two years.

The unit, which opened with 14 beds, provides the same standard of care that is offered at WakeMed's two hospital-based EDs, and is staffed by the same board-certified emergency physicians. The unit is located next to the healthplex's imaging center, which is equipped with a 16-slice CT scanner.

Like hospital-based EDs, a stand-alone ED is staffing intensive, says Knaup. The nurse staffing pattern at WakeMed's stand-alone ED is 4:1, and respiratory therapists, clinical secretaries, patient account representatives, nursing assistants, laboratory technicians, and radiology technicians are available around the clock. 

The patient volume and acuity levels have both exceeded WakeMed's initial expectations, proving that patients wanted and needed the easy access that the stand-alone ED offers.

"Initially, we were expecting to treat approximately 17 patients a day with an acuity level of a 2 or 3," says Knaup. "But, from the beginning, our volume was much higher than that and now averages 100 patients per day with acuity levels of 3 or 4."

Last year, the standalone ED added five minor emergency care beds, which are staffed only during peak hours.

"These beds off-load some of the less acute patients," says Knaup. "As our volumes continue to grow, we continue to add hours in minor emergency care to help with our throughput and ensure that our ED beds are reserved for emergencies."  

Distinguishing ED care from urgent care. From the outset, WakeMed worked to ensure that patients understood that the healthplex freestanding ED was just that-an ED and not an urgent care center.

"It was important in our messaging to make sure people understood that, even though we are 12 miles from the mother ship, this stand-alone ED is merely an extension of the WakeMed ED on our main Raleigh campus, which is our tertiary care facility," says Knaup. ED patients who need to be admitted to the hospital have the option of choosing a WakeMed hospital or that of a competitor.

Opening a second, profitable ED. In 2008, WakeMed opened its second healthplex with a 12-bed ED and the laboratory and imaging services needed to support it. The second stand-alone ED, which serves an average of 45 patients a day, was profitable after only 18 months.

"We learned that we were better off to start with the emergency services and the ancillary services as our core, because that is where you get your foot traffic," says Knaup. "We will grow off of that model."

Interviewed for this case study: Carolyn Knaup is vice president of ambulatory services, WakeMed Health and Hospitals, Raleigh,N.C.

Case Study 2:

Urgent Care Center Supports Massachusetts General in Many Ways

The Massachusetts General Chelsea Healthcare Urgent Care Center sees about 32,000 patients a year, some of whom have left Massachusetts General's hospital-based ED in search of faster treatment.

"The front desk staff at our ED will say, "Listen, you're going to have a six-hour or seven-hour wait here, but you can go across the bridge and you're going to be seen much faster," says Jeffrey Collins, MD, Massachusetts General's urgent care director. 

The Chelsea location, about two miles from Massachusetts General, was not chosen so much as inherited. When a hospital at that site went bankrupt, Massachusetts General took over its contractual obligation to maintain an ED in the community. In 1996, the facility was relocated, at which time the ED was converted to an urgent care center.

Assisting the main hospital handle the patient load. The majority of patients who come to the urgent care center are neighborhood residents or area employees. Located in an urban area with a relatively high percentage of uninsured and underinsured patients, the urgent care center does not break even financially, says Collins.

However, the center does reduce the influx of nonemergent patients to the Massachusetts General's main campus.

Staffed by internists and medicine/pediatric physicians, the Chelsea center provides a range of services. For example, if a patient needs daily administration of IV antibiotics, hospital-based staff insert the lines and urgent care staff manage the antibiotic administration so the patients can stay at home. "Instead of going into a nursing home short-term, the patients can walk into our urgent care for their daily dose of antibiotics," says Collins.

Similarly, if a patient does not qualify for visiting nurse services, hospital physicians look to the urgent care center to work with hospital case managers to provide follow-up care. "The physicians give us a quick call, and we're able to help the patients out," he says. "That's a real advantage on the inpatient side because it helps decrease the length of hospitalization."

Only 6 percent to 7 percent of Chelsea's urgent care patients are transferred for emergency care. "This speaks to the fact that, even in a busy, urban urgent care center, we can handle nearly 95 percent of what comes in the door," says Collins.

Reducing copays for patients.  "It is very efficient for an urban ED to have an urban urgent care center associated with it, and it is cost-effective, too."

ED physicians in the Boston market typically make between $125 and $160 an hour, while the primary care physicians that staff the urgent care center make between $70 and $80. 

The urgent care center is a patient-friendly option because, by tradition, the Chelsea physicians bill at a primary care rate. While a move to an urgent care rate is under consideration, that is still considerably less than ED rates.

"We are able to save the patient a fair amount of money with lower copays and lower total visit costs," he says.

Interviewed for this case study: Jeffrey Collins, MD, is urgent care director, Massachusetts General Hospital.

Lola Butcher is a freelance writer and editor based in Missouri.


Additional Resources

Chamberlain, M., "Lean Techniques Get Results in ED," Healthcare Cost Containment, June 2009.  Faced with an overcrowded and inefficient ED, Convenant Health System decided to use techniques that have worked in the manufacturing industry to make its ED more efficient, productive, and profitable.Read the article. (Subscription required for access.)

"ED Crowding: What Works?" The Business of Caring, Summer 2009.  Nurse leaders are identifying ways to reduce bottlenecks in the ED, while bolstering the case that the ultimate solution for ED crowding lies outside the ED itself. Learn about approaches being explored by the Emergency Nurses Association, HCA, and the University of Kansas Hospital. Read the article.

Ayers, A.A., "Making a Case for Hospital Urgent Care," The Journal of Urgent Care Medicine, January 2009. Outlines how hospital-affiliated urgent care centers can lower the burden on overcrowded EDs, capture new business, and keep existing patients within the health system. Read the article.

Publication Date: Wednesday, July 01, 2009