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Scaling Back: Solutions For Designing Microhospitals

Emerus, the largest operator of microhospitals in the U.S., has partnered with health systems in six states to build community-based facilities, such as this one owned by SCL Health in Westminster, Colo.

Original article available on Healthcare Design Magazine

There’s a new buzz in the U.S. healthcare industry about microhospitals. Seeking a competitive edge, health systems are building these new facility types to extend their brand and target gaps in the market by bringing small, full-service hospitals out into the communities where their patients live. There’s also the business case: Because microhospitals are less complex, they’re cheaper and faster to build than a traditional hospital.

In most states, microhospitals must meet all the same federal and state licensing and regulatory requirements as a traditional hospital (this also makes them eligible for higher Medicare reimbursement than an urgent care center, for example). For that reason, their architecture and design doesn’t stray far from the acute care norm, with most following interiors standards established by a health system to reinforce its brand.

With more than 20 facilities in six states, Emerus (The Woodlands, Texas) is the largest operator of microhospitals in the U.S. Founded by physicians who worked in big-box hospitals, the company wanted to create a healthcare delivery system that offered most of the same services as a traditional hospital—but in a smaller footprint that would allow for faster, more compassionate care to address the needs of the communities it serves, says Daniel Probasco, director of strategy and development at Emerus. “Our president, Dr. John Buck, is a military guy whose main job was to set up mobile ER units all over the world,” he says. “This was the impetus for the initial design of what we consider to be a microhospital.” Emerus has since worked with E4H Environments for Health Architecture (Arlington, Texas) and other firms to design and develop microhospitals for health systems in Arizona, Colorado, Idaho, Nevada, Oklahoma, and Texas—with plans to add 30-35 more to its portfolio in the next two to three years. Most are branded to the health system, but two facilities in Houston remain under the Emerus name. Probasco says the company’s approach is to use a retail-focused distribution model that capitalizes on patients’ desire for convenience in the delivery of healthcare services.

Emerus’ baseline facility is 18,000 square feet with seven to eight emergency bays on one side, a central area with storage and nursing, and inpatient rooms on the other side. Most of its sites also have a second floor for medical offices. Typical hospital procedure areas, such as imaging rooms, are located near the entrance so that one of the first things a patient sees upon entering is the same equipment they’d see in a larger hospital. “When a patient presents in one of our facilities, they know they are going to a hospital and not an urgent care facility,” Probasco says.

Size matters

Microhospitals aren’t used to handle high-acuity patients, such as trauma cases, so patient care areas are simplified and room sizes, including for exam, triage, and treatment, can be reduced. For example, Minneapolis-based AECOM is working with a health system to develop a 13-bed microhospital, with operating rooms (ORs) that will measure close to 500 square feet. “In a large hospital, it would be hard for us to do an OR below 700 square feet because of the equipment that is needed,” says Matt Sanders, a principal at AECOM (Minneapolis). The facility’s single-bed patient rooms will also be smaller, at 325 square feet, compared to those being built at the health system’s new main hospital, which average 350-375 square feet.

Providers still must make room for code mandates, though, such as handwashing sinks and storage, or those features that patients have come to expect, including family zones. “We’re just designing these patient rooms more efficiently and tighter,” Sanders says. “On our smaller facilities, it’s a challenge to be at the bare minimum to reduce cost. Grouping bathrooms and major infrastructure elements can help in being as efficient as possible.”

Because there’s less square footage overall, providers are also reducing public areas, such as waiting rooms, while others are saving space and money by opting to forgo full-service kitchens and instead bringing in food for inpatients from nearby restaurants or a main hospital. “Kitchens are expensive to build,” says Rod Booze, a partner at E4H Environments for Health Architecture (Arlington, Texas). “Many are going micro in their dietary area.”

Elements of success

Although microhospitals are cheaper to build than traditional hospitals, economies of scale are different, so the cost per bed is often higher. To keep costs in line, Catherine Corbin, health market leader at CannonDesign (Chicago), says that some of the design standards of the larger hospital get modified, such as substituting materials and finishes that are similar in look and feel but are less expensive. “Finding the right blend from an aesthetic and budget standpoint is a challenge for our interior design team,” says Corbin, whose firm has worked on several microhospital projects. “Our clients, and their patients, are expecting the sophistication of a hospital environment with the approachability and ease of access of a neighborhood outpatient center.” She suggests using large-format tile in place of terrazzo for flooring, or incorporating select materials, like a feature wall with wood panels or stone, to make a statement at a more contained and cheaper scale.

Like other ambulatory facilities associated with health systems, branding through architecture and design is also key to a successful microhospital project. “Sometimes branding is the building, sometimes it’s the signage, and sometimes it’s just the overall experience,” says AECOM’s Sanders. One strategy to reinforce the aesthetic between a system’s full-service hospital and its microhospital counterpart is by using similar elements, such as decorative and general light fixtures, ceiling elements at reception desks, or nurses’ station design, to carry a branded look from project to project.

The big picture

State regulations have a big influence on where microhospitals are built, and subsequently will determine the ongoing growth of this new facility type. Wisconsin, for example, has a very prescriptive code for hospitals that results in high construction costs, making it hard to build a microhospital there that’s financially viable. Elsewhere, in states with less complex rules, some think that microhospitals are “flying under the radar” of regulators. But that soon could come to an end, potentially bringing more complexities to project delivery. “Microhospitals are getting so popular that they won’t be there for very long,” says Booze.

Sara Marberry is a healthcare design writer, blogger, and marketing consultant based in Evanston, Ill. She can be reached at sara@saramarberry.com.

Sidebar: This, not that

Understanding how microhospitals differ from other small facility types

As microhospitals’ popularity continues to take off, there’s some confusion on its place in the healthcare landscape. For example, comparing microhospitals to ambulatory surgery centers and urgent care centers, the biggest difference is that microhospitals have inpatient beds and are considered fully licensed hospitals with an emergency department, pharmacy, lab, and imaging. Some microhospitals also have primary care, telehealth, dietary services, women’s services, and surgery.

Some also get microhospitals and satellite hospitals confused. Here, it mainly comes down to size, with microhospitals housing about 8-15 beds and ranging in size from 15,000-50,000 square feet, while satellite hospitals typically exceed 100,000 square feet.

A microhospital is also not a rural critical access hospital. For one, microhospitals are typically built in more affluent metropolitan areas within 20-30 miles of a “mothership” hospital that facilitates patient transfers or shared services, such as dietary and meal prep. Critical access hospitals also don’t offer outpatient services.

Rod Booze, a partner at E4H Environments for Health Architecture (Arlington, Texas), says the microhospital is a consumer response model to make access to a hospital more convenient for patients. “Instead of bringing consumers to the hospital, we’re bringing the hospital to consumers,” he says.

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