By JULIE MINDA
For decades many U.S. cities and older ring suburbs have seen their population base shift ever outward into far suburbs and exurbs. To ensure emergency department services are accessible to people in these developing areas, health care providers are building stand-alone emergency departments.
"We're going where the people are," explained Joe Hodges, regional president and system vice president, SSM Health Care of Oklahoma, which includes St. Anthony Hospital of Oklahoma City. "These are underserved areas, in terms of access to care."
St. Anthony is among an increasing number of U.S. health care providers establishing stand-alone emergency departments. Ministry executives said the sites enable them to establish outposts for their full-service hospitals in growing population centers, without committing to inpatient services that the population base doesn't yet warrant. The facilities offer many of the same services as hospital-based emergency departments, but they do not have inpatient beds or intensive acute services like surgical care, nor do they normally have 24-hour observation beds.
Extension of emergency room
In addition to St. Anthony, some Catholic health care providers or affiliates that have opened or soon plan to open these types of emergency departments include Bon Secours Richmond Health System of Richmond, Va.; CHRISTUS Santa Rosa Health System of San Antonio; Humility of Mary Health Partners of Youngstown, Ohio; and TriHealth of Cincinnati.
In each of these systems, the freestanding emergency departments are licensed as part of a full-service hospital that is generally about five to 10 miles away. They are treated as extensions of the full-service hospital emergency departments, with the same policies, hospital charge structures and even the same clinicians on a rotating basis. Each of these freestanding sites is subject to the Emergency Medical Treatment and Active Labor Act; they follow the same charity care policies as their full-service hospital counterparts; and are staffed 24 hours a day by in-house board-certified physicians. All have nurses and other clinical staff with emergency department certification as well as critical care specialization. All have ready access to radiologists and pharmacists — in most cases through telemedicine or on an on-call basis.
The freestanding departments generally are capable of treating patients suffering heart attacks, strokes, respiratory distress, head injuries, abdominal pain, dehydration and orthopedic injuries. However, they do not have the surgical or trauma capabilities of their full-service hospital counterparts, and so if patients with such needs come to the freestanding sites, clinicians stabilize them and transfer them to the hospital.
While most patients arrive by car, some are delivered by ambulance — the freestanding sites have established protocols with emergency medical technician teams to determine when they should go to the full-service hospital and when to go to the freestanding site. People requiring trauma surgery most likely would be taken directly to the full-service hospital emergency department to be stabilized and prepped for surgery. Heart attack victims may be stabilized at the freestanding sites and then transported to the catheterization lab at the full-service hospital. Some of the freestanding centers have helipads; all have immediate access to ambulances for transport.
Patrick Carrier, president and chief executive of CHRISTUS Santa Rosa, which is opening two freestanding sites later this year, said only about 12 percent of patients in its hospital emergency rooms require admission, and CHRISTUS expects its experience at the new sites to be similar.
An increasingly popular option
According to data from the American Hospital Association, the number of freestanding emergency departments increased 65 percent between 2004 and 2009. (The Centers for Medicare and Medicaid Services began recognizing freestanding emergency departments as a provider in 2004.) A report from the California HealthCare Foundation said by the end of 2008, there were more than 200 freestanding emergency departments operating in at least 16 states.
That study said that while such facilities have been around since the 1970s, they have gained popularity among health care providers since 2000 as those providers have tried to meet an increasing demand for emergency services, differentiate themselves from competitors and gain increased market share.
Ministry providers said their key motivations were to create a "pressure valve" to relieve emergency department overcrowding and to improve access to emergency care for people in underserved suburbs. Those who have opened such sites say they've seen volume decrease in their full-service hospital emergency departments.
Branching out
Ministry providers said they generally locate freestanding emergency rooms where there are no other 24-hour emergency centers. But the sites also can act as an outpost for establishing other services, such as primary care, on the freestanding emergency department campus or nearby. The providers said the freestanding emergency departments improve their name recognition and extend their ministry into new markets.
Steve Mombach is vice president of ambulatory services for TriHealth, which operates Cincinnati full-service hospitals Bethesda North Hospital and Good Samaritan Hospital. He said TriHealth located a freestanding emergency department on a large parcel of land in Cincinnati's Western Ridge suburb to open up many options for growth as the population continues its predicted increase.
HMHP opened one of its three freestanding emergency departments in 2001 as a modular facility in Boardman, Ohio. As it built a patient base and name recognition it erected a permanent emergency department. In 2007 it incorporated that structure into a new hospital, said Genie Aubel, president of that campus. Paul Olivier, HMHP's senior vice president of business development, said HMHP's freestanding facilities were the first Catholic health services in each of the three communities.
Satisfied patients
Kyle Nondorf, vice president of St. Anthony in Oklahoma City, noted that people can get in and out of freestanding emergency departments more quickly than units connected with hospitals because they are not competing for services with inpatients. He said analysis has shown patients will be seen and treated in an average of 90 minutes at freestanding sites, compared with four hours at hospital emergency departments.
Kevin Sheppard, vice president of ambulatory services for Bon Secours Richmond, said that it's easy to park at Bon Secours' freestanding facility in Midlothian, Va., and the pared down facility may be easier for patients to navigate than a large hospital campus.
Sheppard added that with the new site situated closer to the outskirts of Richmond than the medical center, it allows for nearer access for more rural patients.
In line with mission
Ministry representatives who spoke to Catholic Health World say the facilities have been successful in attracting patients — and returning profits.
In some communities where freestanding centers have been proposed or opened, existing hospitals and others in the community have questioned whether the stand-alone sites have an unfair advantage because they're often located in more affluent areas with larger percentages of insured patients — a concern documented in the study by the California HealthCare Foundation.
Olivier of HMHP noted that while many such facilities are located in suburbs, HMHP did not choose its sites based on household affluence or insurance coverage. "The original issue for us is: Where are the people and where do they need services? There really are no emergency departments in these areas," he explained.
Carrier added that in cases in which these emergency departments are profitable, the funds are used to bolster less profitable — but mission-centric — services. For instance, profits are used to bolster the system's safety net hospital that serves a large indigent population.
Hodges added that the freestanding sites alleviate traffic in hospital emergency departments, thereby freeing up capacity for people using those full-service facilities.
Olivier said that like many health care providers, many in the ministry are likely to continue building stand-alone emergency departments. "This is a trend that will be supported by what the customer and the community is asking for. They want this level of care" and convenience, he said.
Some ministry stand-alone emergency departments, at a glance
Bon Secours Richmond Health System, Richmond, Va.
- The 16-bay Bon Secours St. Francis Watkins Centre opened Nov. 1.
- The campus also has diagnostic imaging and a women's center.
- Located about five miles from Bon Secours St. Francis Medical Center.
- The Bon Secours system's second freestanding emergency department in Virginia.
CHRISTUS Santa Rosa Health System, San Antonio
- Opening two freestanding emergency departments later this year, each with 10 bays.
- One is in a San Antonio suburb less than 6 miles from a CHRISTUS full-service hospital; and the other, in New Braunfels, Texas, less than 5 miles from another CHRISTUS hospital.
- Both will have imaging facilities. Looking to add primary care nearby.
Humility of Mary Health Partners, Youngstown, Ohio
- HMHP's St. Joseph Hospital of Warren, Ohio, already had a freestanding emergency department when HMHP acquired St. Joseph in 1995. That department is in Andover, Ohio, more than 30 miles from Warren.
- HMHP established another stand-alone emergency department in Boardman, Ohio, in 2001, and then built the site out over time to a full-service hospital. Another HMHP full-service hospital, St. Elizabeth Health Center, is about 5 miles away, in Youngstown.
- In 2004, HMHP opened a freestanding emergency department in Austintown, Ohio, about 10 miles from Youngstown. It has a laboratory, radiology and other outpatient services.
SSM Health Care's Oklahoma City region
- SSM's St. Anthony Hospital opened two freestanding sites in January.
- One is about 10 miles from the full-service St. Anthony, and the other, about 13.
- Each has 12 exam rooms.
- Both sites also offer diagnostic imaging, breast care, sleep care and family physicians.
TriHealth, Cincinnati
- Its stand-alone emergency department in Western Ridge, Ohio, is about 10 miles from its affiliate, Good Samaritan Hospital in Cincinnati. It has 17 bays.
- Its stand-alone emergency room in Arrow Springs, Ohio, is about 15 miles from its Bethesda North Hospital in Cincinnati. The Arrow Springs site staffs 18 bays but has the capacity to expand services to 24 bays.
Closures of hospital emergency departments
While the number of freestanding emergency departments has been rising, the count of hospital-based emergency departments has been falling, with some of the departments closing as their host hospitals closed, and some closing as their host remained open.
According to a May 2011 report in the Journal of the American Medical Association, the number of hospital-based emergency departments has declined by nearly 30 percent in the last two decades. The report specifies that its statistics are for facilities that are not in rural areas.
The researchers said the hospitals most likely to close were those that were smaller, had low profit margins and were located in areas of high poverty and high levels of uninsured.