Less Care, More Health: How Transformations in Healthcare Will Impact Facilities

The hospital of the future wants to keep people out. During a "State of the Industry" panel discussion at HealthSpaces, real estate and facilities leaders from diverse healthcare organizations discussed how rapid changes in the industry—including how the ideological shift from "care" to "health" seeks to keep people from even having to go to the hospital—are impacting the built environment.

The panel featured: Tonia Burnette, Senior Director, Architecture + Planning at Johns Hopkins Medicine; Cleve Haralson, VP of Real Estate & Capital Development at Kindred Healthcare; Jeff Land, SVP, National Real Estate Services at Common Spirit Health; and John Milne, MD, SVP, Real Estate & Construction at Providence St. Joseph Health. Jake Rohe, Partner & SVP of Development at Pacific Medical Buildings, served as moderator.

Population Health

Rohe kicked off the discussion by asking each of the panelists for their take on one of the biggest shifts happening in the healthcare industry today: the shift from treating those who get sick to helping people stay healthy in the first place.

John Milne, SVP of Real Estate & Construction at Providence St. Joseph Health, said that Providence is currently making the pivot from being a "sick care company" to a "health company." Historically, master planning has occurred around the hospital campus with the doctors, caregivers, and other employees at the forefront and the intent of bringing patients in once they get sick. But with the goal now to keep people out—keeping them healthy so they don't get sick in the first place—master planning needs to be more community-based.

"As we think about master planning, our team has begun to ask, 'What does it mean to do community-based master planning? How do we embed social determinants of health? How do we think about housing? How do we think about the broader community beyond the four walls of the hospital?'"

From a real estate and built environment perspective, he said, that means incorporating a larger group of partners, including companies that do multi-family housing, retail, and commercial real estate projects, on broader scale development with healthcare as a component.

Jeff Land, SVP of National Real Estate Services at Common Spirit Health, said that healthcare systems also need to provide med/surg care in the home. A sick person coming into a facility runs the risk of getting sicker from hospital-acquired infections, or has a longer recovery period due to lack of rest from hospital noise, frequent interruptions, and so on—all things that can be avoided if care were provided in the comfort of a patient’s home. What this means for real estate, of course, is potentially a drastic reduction in the need for beds.

At Kindred Healthcare, their focus is specifically on the aging population, which has more chronic and co-morbid conditions, said Cleve Haralson, VP of Real Estate & Capital Development. There are currently 54 million people on Medicare today, with 11,000 additional people enrolling every single day. By the year 2035, the 65-and-older population will outnumber the 18-and-under population for the first time in history.

"Our goal is to team up with health systems for long-term acute care, in-patient rehabilitation, and behavioral health, to be able to serve that aging population and provide [those services] in their communities," Haralson said. To do this, they're building smaller, fully licensed hospitals that can care for those patients that need to be admitted for several weeks but can't be accommodated by Kindred's short-term acute care partners.

In Baltimore, Tonia Burnette, Senior Director of Architecture + Planning at Johns Hopkins Medicine, said that their biggest new initiative is focusing on behavioral health, building residential crisis centers to prevent the influx of people coming into the emergency room for behavioral and psychiatric services.

"Otherwise we're just building bigger and bigger emergency departments and psych departments to house these people for [months at a time] because there's nowhere else for them to go," she said. "If we can stabilize them at home or in crisis centers, we'll do a lot better."

Behavioral Health

Burnette also noted that they're seeing the comorbidities between medical and behavioral grow. One hospital in their system estimated that 15 to 20 percent of their patients have comorbidities with behavioral or psychiatric health issues.

"Think about that in terms of what those rooms need to look like," she said. "We can't just count on one-on-one sitters."

The solution, she says, is residential crisis centers. Johns Hopkins Medicine currently has 88 adult behavioral health beds and they serve those 88 patients well. The length of stay is longer, but the readmission rate is very low.

"A lot of these patients may stay longer than they do in other places, but they're getting out and being able to stay out of the system," she said.

Across the board, behavioral health is becoming a much more significant focus for each of these healthcare providers.

Kindred is working with their partners to build 15 new hospitals in the next two years, all specializing in behavioral health and in-patient rehab. "It's not a sexy role. People don't want to spend a lot of money on it," Haralson said. "For us it's really about finding the gap [in care] that's absolutely necessary [to fill]. Fortunately for us, we've teamed up with people that also see the benefit and want to provide that service." 

Milne reemphasized his point that a broader spectrum of "community health" needs to be addressed in order to catch all of the people who are "falling through the gaps" and ending up in acute care because there isn't anywhere else to put them. 

"The fact that we're trying to keep people out of the hospital as best we can means the infrastructure we're trying to build beyond [acute care] is much more important than it ever was," he said. This means, among other things, looking at senior housing and integrating more into the post-acute environment to make sure that the transitions of care from one level to the other are seamless and the patients are able to move easily through them, with the goal of reducing 30-day readmissions.

Haralson agreed. "Out of 16 million discharges annually from short-term acute care, about 43 percent, 7 million people, are going to require some sort of post-acute care, otherwise they're going to end up back in the hospital and those readmissions aren't free," he said. "That's why this is such a big deal and why we're actively working to fill that gap with our partners." 

Future Flexibility

Another big topic of conversation for the panel was designing buildings with future flexibility in mind so that they don't just serve today's needs, but can serve the changing needs of the coming years and decades. But, as Rohe pointed out, flexibility comes at a cost.

"If you have a long-term perspective and there's a business logic to look out 30, 40, 50 years [into the future of this facility], ultimately that up-front premium for future flexibility is well worth it," he said.

One hurdle is the finance team, Burnette said, and getting them to sign off on a future-oriented capital expense.

"We have to make sure that every one of these capital dollars is really bringing us the ability to do higher quality care at a lower cost," she said. "Sometimes a little bit bigger of a building makes sense, so it looks like a higher initial capital investment but we know over time that we're going to get more bang for our buck out of that."

As technology rapidly changes, building for future flexibility means building for the unpredictable decades in advance. Additionally, concerns over climate change and the carbon footprint of buildings and construction have become more of a factor than ever before, and is another component that has to be calculated into the cost of projects.

"It has been an ongoing challenge because you've got that lump sum right at the front; how do you get past that?" said Milne. "We're getting better at looking at what the energy utilization is, what the operating costs are moving forward, and how they can be optimized over the decades-long lifecycle of the building. We're able to say, 'Let's optimize the existing operations before redesigning around processes that may or may not be effective.'"

Milne said that the only thing we can really know about the hospital of the future is that it's going to be different. There might be more hospital-at-home services, so that can be factored into bed demand forecasting. But, ultimately, what the "chassis" is going to look like moving forward needs to be adaptable.

"Agility in the future is really more about rapid response," Land said. "We need to know if what Apple is doing next is going to fit into our continuum, and if it does, then how fast can we adjust to it." For that reason, he continued, partnerships become incredibly important—partnerships with major tech companies, as well as partnerships with major retailers hoping to cause major disruption in the healthcare industry.

"Agility in the future is really more about rapid response"

"There's going to be partnering all over the place on locally branded items," Land said. Milne agreed: "I think you're going to see partnerships going forward that you probably wouldn't have imagined even five years ago. As we're looking at how we can deliver care and serve these communities better and more efficiently, I think you're going to start seeing more interesting bedfellows as we continue to move forward and look at that broader spectrum."