How Urgent Care Clinics are Evolving

Besides relying on walk-in traffic from patients, clinic leaders are also exploring new medical services to differentiate themselves and to better coordinate care.

This article appears in the September 2015 issue of HealthLeaders magazine.

It is hard to get a firm count on the number of urgent care centers in the United States. The Urgent Care Association of America says there are more than 6,400, while the American Academy of Urgent Care Medicine puts the number as high as 9,300. What is clear, though, is the growth of this care model. As hospitals and health system leaders evaluate the risks and rewards of urgent care, there are strategic considerations that may seem unimportant on the surface, but can lead to complications later on.

Take, for example, the difficulty in determining the number of urgent care centers. It stems from the lack of standardization in states' regulation of urgent care facilities. Generally, most states view urgent care centers as a physician office with extended hours. A few states, such as Arizona, attempt to regulate urgent care clinics through licensure. And some states require a certificate of need for urgent care centers. The differences in state regulations are an important issue, especially if a healthcare organization's footprint extends across state lines.

Another issue to consider is whether an urgent care center perpetuates the fragmented nature of healthcare. Hospital and health system leaders have repeatedly said that care coordination is imperative to achieve better quality, cost, and outcomes. Will patients, who are in a hurry, especially when seeking an urgent care center, get so used to the easy access and quick service that they forgo seeing or keeping their primary care physician in the loop?

"We tell patients that we do not want to be their primary care doctor," says Robert Rankins, MD, founder of E-Care Emergency Centers, a McKinney, Texas–based network of four for-profit freestanding emergency and urgent care centers that also provide urgent care services in the Dallas suburbs. "I don't want to see them for their high blood pressure and diabetes. We try to get patients who come in here for a primary care reason hooked up with a primary care physician. If they come in with a sore throat and they couldn't get in to see their regular doctor, we tell them to follow up with their primary care doctor because that is not what we want to compete with. We try to make that very clear."

Success key No. 1: Understand regulatory environment

The urgent care business model that Rankins developed—a facility that can treat urgent care and emergency patients—is both a cautionary tale and success story. Rankins says early on he learned that to minimize patient confusion and maximize volume, he needed to deliver what patients wanted and needed.

"What we're doing is a cost-savings for the consumer," says Rankins, who is a board-certified emergency physician. "Our facility is a one-stop shop," he says, noting that patients should be able to come here, receive the care they need, and not worry if they should have gone to an ER or an urgent care center. "We're trying to bring them both under one roof."

Rankins originally opened up E-Care as an urgent care center, but in 2010 when Texas began licensing freestanding emergency departments (FED), the state treated E-Care as a FED only, so Rankins switched gears to offer just emergency care. He says the effect was confusing for patients, payers, and even for him.

"We had some insurance companies who would pay us for emergency care and some would not," says Rankins. "I had a Blue Cross Blue Shield patient with chest pain, and we did a complete cardiac workup and billed it as an ER visit. They denied us, so we rebilled the visit as an urgent care one because we had to get paid something. The insurance company said, 'You're not urgent care,' and that was the impetus for me to become both."

Rankins says patient volumes are still recovering from the confusion, but being able to treat urgent care cases has helped keep his combination model sustainable. Prior to the 2010 FED rules, he says E-Care was seeing 70 patients per day at each location. But then that number dropped sharply, and the centers are now up to 30 patients per day.

"It's been a challenge, but we're getting there," he says.

A significant obstacle is the overhead a FED incurs without the patient volume to go along with it. FEDs have the same requirements as a hospital-based EDs: Have at least one ambulance bay, be open 24/7, have emergency-trained physicians and nurses on site, and have appropriate diagnostic equipment. But what's not coming through E-Care's doors quick enough are ambulances with patients who need emergent treatment but not a hospital admission.

Rankins says that's because there is no statute that requires emergency medical service crews to use FEDs, which are in direct competition with area hospital–operated EDs and want the admissions.

"It's not fair, in my opinion, to be prepared for emergency traffic but not require the other team to play with us," he says. "We need to be able to downsize our staff at night and cut expenses. It's not right to say, 'You have to be ready to play, but we're not going to force them to throw the ball to you.' We want emergency cases, we have to be prepared for them, and it costs us the same to staff. What's happened is FEDs have the same expense and overhead as a hospital-based ED but nothing coming in."

Right now, Rankins estimates that, depending on the time of year, between 190 and 273 patients per month per location are true emergency cases at E-Care facilities. That represents between 20% and 30% of E-Care's patient volume. He'd like to increase that volume, but by having a combination urgent care and FED, Rankins can afford to ride out state healthcare regulations. Rankins is on the board of directors of SAFER-Texas (State Association of Freestanding ERs), an organization made up of FEDs that advocates for its members. As vice president of advocacy for SAFER-Texas, he is actively involved in state legislation that can hinder or help FEDs.

Success key No. 2: Align urgent care with emergent care

In St. Louis, competition for urgent care patients is fierce, says Beverly Bokovitz, MSN, RN, NEA-BC, chief nursing officer at St. Anthony's Medical Center, a 550-staffed-bed nonprofit Catholic hospital that has four urgent care centers. Bokovitz is also part of the four-member St. Anthony's Office of the President, which includes new CEO David Sindelar, a unique leadership structure that complements the traditional and singular CEO role.

Bokovitz says St. Anthony's urgent care centers are strategically placed in locations surrounding the hospital. The busiest center is Lemay Urgent Care, serving 20,000 patients annually. It is about 5 miles from the hospital.

"We're in a very competitive market, and looking geographically at locations made sure our strategy is in alignment with our demographic studies," says Bokovitz, noting that there are 45 urgent care centers in metro St. Louis, including a competitor directly across the street from St. Anthony's Medical Center.

St. Anthony's total urgent care volume for all four centers in 2014 was 77,357, and brought in $28 million in revenue. Bokovitz says so far in 2015, volumes are up by 10%, primarily because the urgent care centers are doing more than seeing patients with a cough, sore throat, or broken bone.

"Urgent care allows you to have another healthcare setting in a different location," she says. "If you put yourself in the box of 'You're just an urgent care,' I think that's probably a mistake. The best strategy is to think about what other types of services you can offer if you have multiple locations."

The biggest contributor to the urgent care patient volume increase this year is occupational medicine. In 2014, the hospital's ED was reorganized to improve wait times, and in the process, urgent care was reorganized, too, because the urgent care centers were a main source of ED patients. That prompted a new organizational chart that combined occupational medicine, urgent care, and community health and wellness (including employees) under ambulatory care.

Charles J. Lewis, MSN, RN, is the executive director of emergency services and ambulatory care at St. Anthony's Medical Center. Lewis says when the system did its operational assessment of ED and urgent care services, it was clear that the occupational medicine work was siloed, resulting in operational inefficiency. Before the reorganization, patients who came in for occupational medicine needs followed a different workflow because not everyone was trained to perform a blood alcohol test or other tests needed in order to be cleared for employment. It fostered an us-versus-them attitude among staff, he says.

"We have varying levels of service and offerings within occupational medicine that includes worker injury and population health preventive-type services, like community wellness and fitness," says Lewis. "Blending occupational medicine with urgent care was a natural fit. We have to see those patients in a brick-and-mortar setting, and we had those resources available through the four urgent care locations, so why not blend the staff and resources together?"

Now, all four urgent care centers can see an initial worker injury; the longer-term follow-up is done at two of St. Anthony's urgent centers.

"We have occupational medicine care at every location," says Lewis, who also says that ability to provide occupational medicine is an opportunity to differentiate St. Anthony's from the crowded urgent care market in St. Louis.

"You have to do it very well and have a high level of customer service for the clients," he says.

Reorganizing emergency medicine and urgent care under one leader has helped the system align its goals, says Lewis, especially because of the historically rocky relationship between EDs and urgent care centers.

"The ED physicians work closely with our urgent care physicians," says Lewis. "And I meet regularly with senior leaders of our physician group, and we talk about access. We share EMRs, so if a patient is seen in urgent care, it's very easy for the primary care or the ED physician to be able to see what care has been provided and what the plan was for that patient."

Care coordination is a key issue for healthcare executives. Poor postacute care can lead to readmissions penalties, lapses in quality, and lackluster patient satisfaction evaluations. If a patient seeks care in an urgent care center, that episode may or may not make it back to the patient's PCP.

In 2013, a brief developed by the Center for Studying Health System Change noted that among the 30 urgent care, hospital-based ED, and health plan executives it interviewed, urgent care centers weren't major disruptors to the coordination of patient care, but it also was not a big priority, especially for the urgent care centers that were not affiliated with a hospital or health system.

Steve Sellars, MBA, is CEO of Premier Health Urgent Care based in Baton Rouge, Louisiana, which sets up joint ventures with hospitals to own and operate urgent care centers; he says coordinating care is an important issue that operators shouldn't overlook.

"We see a lot of different things going on in urgent care centers," says Sellars, an Urgent Care Association of America board member since 2011. "It is an access point to care within the health system, and our partners typically have a family of services, so it's about getting the patient into the right level of care. The UC industry is committed to making sure that communication between primary care, urgent care, and specialists happens."

St. Anthony's shared EMR helps the system keep a patient's care coordinated. There are no more repeated studies if a patient is transferred from an urgent care center to St. Anthony's Medical Center ED, and there are no more duplicate copays. Lewis says that a patient's urgent care copay will be applied to the ED copay or inpatient bill, if that care also is required. The EMR allows the urgent care centers to note that the patient is an urgent care transfer, which prompts the ED physician to look into the record to find completed labs and tests.

Another improvement from the reorganization that benefits urgent care and emergency patients is the direct-to-ED-bed policy. If a patient is seen in a St. Anthony's urgent care facility but needs to transfer to the ED, St. Anthony's Medical Center will hold an open ED bed for 30 minutes.

"We script what urgent care will say," says Lewis. "The urgent care staff are trained to say, 'Mr. Smith, if you go now, the ER is holding a bed for you.' And when the patient gets to the ER, we have a script there as well: 'We've been expecting you,' and we place them directly into their ED bed. Their wait time starts as soon as they're seen in urgent care."

This direct-to-ED process also is available to St. Anthony's Medical Center patients. Bokovitz says the new process, developed by both ED and urgent care physicians, improved wait times tremendously. In 2013, the average amount of time an urgent care patient waited for an ED bed was 125 minutes. In 2014, that was reduced to 19 minutes.

In addition to supplementing urgent care offerings with occupational medicine, Bokovitz also says St. Anthony's Medical Center is exploring the possibility of offering primary care services, telemedicine, and a partnership with retailer CVS.

"We're in the midst of change with urgent care, and you really have to start thinking out of the box: What are other ways we can use urgent care centers?" says Bokovitz. "We're in a competitive market. If we were the only people in town, we'd have less to worry about, but we're not, so we need to think about the other ways we can serve patients."

Success key No. 3: Trending the future

Torrance, California–based HealthCare Partners, a division of DaVita HealthCare Partners, which operates and manages medical groups and urgent care centers in California, Florida, Arizona, Nevada, and New Mexico, is also experimenting with diversifying its urgent care services.

For example, its urgent care center in Pasadena, California—HealthCare Partners' largest urgent care center in California, where physicians see 5,000 patients a month—has added two specialty care clinics within the past year based on the needs of patients it was seeing.

"Cardiology is a new department we added in the last year," explains Claudia Pfeil, MD, one of two lead physicians who oversee the Pasadena urgent care center site, and chair of the HealthCare Partners urgent care center steering committee, a group of administrators, nurse leaders, and lead clinicians from other urgent care centers who meet to share best practices.

"The cardiologist works synergistically with the urgent care doctors to treat chest pain and other chronic cardiac conditions in the urgent care. The cardiologist actually can perform on-site stress testing for patients as well, so that's been an exciting area of development."

Pfeil says another specialty clinic at the Pasadena site is whole-body wound care.

"These specialty departments have evolved either out of the urgent care, based on the need of the patients that we're seeing here, or we've brought them in because the department, such as cardiology, will work synergistically with what we're doing."

The Pasadena urgent care location is one of eight urgent care centers owned by HealthCare Partners. In June, it marked its one-year anniversary at a new location. According to the Urgent Care Association of America's benchmarking report, expansion is a trend: 60% of urgent care centers accommodated growth by buying another practice, adding space, or building a new location.

The Pasadena location's new space expanded from 25 treatment rooms to 40; it also has nine observation units. It is open 24-hours a day, 365 days a year, and the observation rooms function the same as a traditional hospital.

"It was one of the main incentives to move to a larger site," says Pfeil. "It doubled our observation capacity."

HealthCare Partners Pasadena urgent care center has not always been open 24/7, but the impetus to expand its hours seven years ago was because Pfeil says its patients are older and sicker, and were staying in the urgent care center longer.

"Prior to going 24/7, by 10 or 11 o'clock at night, we were scrambling to try to transfer patients out," says Pfeil. "Typically they would end up going to the ED. This way, we have more time to really provide better care and get them directly admitted to the hospital or into a skilled nursing facility."

HealthCare Partners also has a shared EMR system that connects patients to its employed hospitalists at area hospitals and to its primary care physicians. HealthCare Partners also can provide a heightened level of coordinated care.

"About 60% of our patients are with HealthCare Partners' HMO, and about 40% are PPO," she says. "Having an integrated EMR makes a huge difference. It's critical for us to provide that coordinated care."

The issue of educating patients on the difference between emergent and urgent care is something that is ongoing with aggressive marketing campaigns, but Pfeil says she also makes sure that referring providers know the difference, too.

"The majority of primary care doctors will actually come through and meet with me," says Pfeil. "I give them an overview of what we can do here in urgent care, what kind of services we have, so they have a mental image of what our clinic looks like."

Urgent care centers have an opportunity to meet patient access needs and coordinate care, but it must be done thoughtfully, says Sellars.

"We have an aging population, a looming shortage of primary care physicians, and more insured people in the marketplace. When you lump all that together with what urgent care provides, it's safe to say that urgent care will play an important role in the healthcare system going forward."

Reprint HLR0915-8