Patient demand for access fuels walk-in clinic growth

May 1, 2016


Health care systems know today's patients want what one executive termed "on demand" care — walk-in or same-day appointments for immediate, non-emergency health care needs — and health care systems are redoubling their investments in urgent care clinics and nurse practitioner-led clinics in retail settings, to meet consumer expectations.

The Urgent Care Association of America says the number of urgent care centers has increased significantly in recent years, though it cautions an exact rate of growth is hard to pin down. It counts about 7,100 full-service urgent care centers currently operating in the United States; it says other estimates put the number at roughly 9,000 clinics when retail medical clinics, such as those located inside drugstores, are included in the count.

Dr. Amy Gumuliauskas, a pediatrician with SSM Health at its St. Anthony Healthplex North in Oklahoma City visits with Oklahoma City siblings and pediatric patients, from left, Nestor Wheeler Ramirez, 8, Priscilla Wheeler, 11, and Inzly Ramirez Wheeler, 3.

The demand for care in convenient settings with short wait times comes as patient visits are in decline at acute hospitals nationally with utilization decreasing about 3 percent or 4 percent a year, said Dr. T. Clifford Deveny, Catholic Health Initiatives senior vice president for physician services and clinical integration. Health care systems are prioritizing efforts to keep patients healthy, but at the same time health care systems want to offer choices that will attract patients. "Everyone's trying to figure out how to keep the factory full," he said.

A RAND Corporation study released earlier this year said retail clinic visits for low-acuity conditions represented new utilization and a modest increase in health care spending.

Executives interviewed for this story said well-planned urgent care and/or retail clinics can offer care that's more accessible and less expensive than an emergency room visit.

Tailoring to the market
CHI executives adapt their approaches to the market. "We have a set of guidelines and guardrails, but you still are responsible in your market to figure out what is appropriate in your location and what your population wants," Deveny said.

Many CHI primary care practices have shifted their hours to include more early morning, evening or weekend appointment slots. Primary care practices are also leaving open some room in the schedule each day to accommodate walk-ins or same-day appointments, Deveny said. CHI is co-locating some of its primary care practices with urgent care clinics, with some staff available to float between settings, depending on demand, said Deveny.

Tacoma, Wash.-based CHI Franciscan Health has formed an equal partnership with the urgent care company CityMD to build urgent care centers in CHI Franciscan's Seattle and Tacoma markets. The partners haven't yet announced the number of clinics they'll open together. CityMD operates more than 50 urgent care centers in the Northeast; the co-branded CityMD/CHI Franciscan urgent care sites will be CityMD's first in the Pacific Northwest. The clinics will augment existing CHI Franciscan primary care and its existing Franciscan Prompt Care and Harrison Urgent Care sites, mainly located in the Puget Sound area, according to information from the partners.

Ketul J. Patel, CHI Franciscan's chief executive and CHI senior vice president for divisional operations, said CHI Franciscan considered several urgent care models and chose CityMD because the company staffs with emergency medicine doctors and has an aftercare program. CityMD staff follows up with each patient to answer questions related to that person's care or medication. CityMD/CHI Franciscan staff will refer urgent care patients who need follow-on care to CHI Franciscan providers.

Providence expands its portfolio
Renton, Wash.-based Providence Health & Services is building 50 Express Care clinic sites during an 18-month time frame. The clinics will either be freestanding or be housed within Walgreens stores. They'll be open seven days a week, 12 hours a day. They'll be staffed by Providence nurse practitioners and medical assistants with a supervising physician medical director from Providence.

The retail clinics in Washington and Oregon will have footprints of roughly 800 to 1,000 square feet and provide basic care including vaccines, school physicals and treatment for ailments like persistent coughs and stomach aches.

CityMD, with locations that include walk-in, street-level urgent care clinics like this one on the East Coast, has partnered with CHI Franciscan Health to build similar co-branded urgent care sites in Washington’s Tacoma and Seattle markets.

A few of the clinics opened early this year, including one in Renton. The clinics in retail pharmacies are being branded as Providence Express Care at Walgreens or Swedish Express Care at Walgreens. (Swedish Health Services is a Providence affiliate.) Initially, these in-store clinics will be in the Everett, Wash.; Portland, Ore.; and Seattle areas, said Mike Waters, Providence senior vice president of physician services.

Walgreens spokesperson Jim Cohn said Walgreens has a two-pronged strategy for clinic growth, moving forward with both clinics managed by Walgreens and clinics owned and operated by health care systems, which deepens relationships between health care systems and the drugstore chain. "We see value in both," he said.

When the clinic deal with Providence was announced in August, the partners called it a "new collaborative services model," in which the health care system owns and operates the clinic in leased space in a Walgreens. Providence and Walgreens created a joint governance committee to evaluate opportunities for improvement and innovation in the clinics and to share best practices.

The Express Care clinics will tie into Providence's electronic medical record and staff will make referrals for additional care within the Providence system, when needed. For instance, Waters said in one case a woman who sought treatment for a sore throat at an Express Care clinic exhibited symptoms of depression — she said she was struggling with the recent death of a family member. She got a referral and same-day appointment to see a behavioral health clinician at another Providence location.

In time, Providence and Walgreens want the in-store clinics to provide medical management for chronic conditions. Walgreens pharmacies currently offer medication adherence programs, including patient consultations with a pharmacist about new medications and follow-up phone calls from pharmacy staff to check in with patients and answer questions. Waters envisions greater collaboration between clinicians and pharmacists when they see a patient in need of help managing a chronic condition, with clinicians closely tracking the patient's care needs, and the pharmacists assisting with medication adherence.

In Southern California, Providence is pursuing a different model of on-demand care. It recently invested in a joint venture that will offer urgent care as well as services beyond the norm for that category of clinic. (See sidebar.)

Communicating across care settings
St. Louis-based SSM Health said on April 18 that it will own and operate the clinical practice and management of 27 retail health clinics within Walgreens stores across the St. Louis region, including four clinics in Illinois. The clinics will become part of SSM Health this fall, as an extension of the SSM Health Medical Group. They will be called SSM Health Express Clinic at Walgreens. SSM already collaborates with Walgreens on some of the retailer's walk-in clinics; at those clinics, nurse practitioners hired by Walgreens are supervised by SSM physicians.

SSM separately has 14 urgent care clinics in its four-state market area: Missouri, Illinois, Oklahoma and Wisconsin.

SSM also has built nine healthplexes, locations that cluster primary care doctors' offices with laboratory and imaging capabilities; some have ambulatory emergency rooms. The healthplexes are designed to be "a destination of choice" for patients seeking prompt care, said Dr. Shane Peng, SSM's president of physician and ambulatory operations.

"Patients are not homogeneous," Peng said. Some value the quick access to a nurse practitioner at a walk-in clinic, but others prefer to see a doctor in an office setting even if it means a longer wait for an appointment. Some choose a health provider based on proximity to their home or workplace, while others will travel further to a healthplex for the added convenience of having multiple services under one roof. And patients may change their preference based on their reason for seeking medical care.

"Our responsibility is really to provide convenient, accessible, affordable health care to our patients, while not losing sight of the fact that we want all these venues of care to be integrated," Peng said. The health care system continues work to provide electronic medical record systems that allow clinicians to access and update a patient's records in its various care settings. Clinicians who see a patient for episodic care ask the patient if he or she has a medical home, and will help the patient set up an appointment for a primary care provider in the SSM system, if the patient doesn't have a medical home and wants one. Peng said, "I think what we're moving toward is creating an ecosystem that will provide well-coordinated, integrated delivery of care for our communities."


Providence Southern California partners to expand care access

Providence Health & Services' Southern California region has entered into a joint venture with an organization that provides care at a level up to and beyond urgent care, but below emergency department-level care.

Providence and "Exer — More than Urgent Care" said their partnership will increase patient access to care while lowering care costs.

Providence Southern California and Exer formed the joint venture on Jan. 7. Exer, a privately held company, says it operates walk-in clinics providing care at a level beyond urgent care in Southern California's Northridge, Calabasas, Beverly Hills and Newbury Park — cities currently not served by a Providence Southern California urgent care site or emergency department. Providence Southern California has six hospitals and a network of primary care clinics, urgent care centers and other facilities in Southern California's South Bay, Westside and Greater San Fernando Valley.

Providence made an investment in Exer's parent company, Exer Holding Co., to acquire equity and form the joint venture. The two joint venture partners would not disclose Providence's investment, nor its ownership share. The Catholic health provider's capital will fund the development of new Exer clinics, within and contiguous to Providence's service areas in Southern California. Plans call for four new sites this year, including one in the San Fernando Valley and one in the South Bay region.

The partners said during the joint venture's first three years of operations, profits will be reinvested into the joint venture to fund new sites. After three years, the joint venture's profits and losses will be allocated according to each partner's ownership stake, the companies said.

The partners said locating Exer clinics in or near Providence service areas will decompress Providence's crowded emergency departments in Southern California, expanding emergency department capacity to accept higher-acuity patients while reducing the incidence of ambulance diversion. Providence said with the additional capacity of the Exer clinics, it could "potentially redeploy our urgent care centers to expand primary care access."

The joint venture's board of managers will have eight members, with equal representation by each of the two partners. Each partner also will be equally represented on a four-member executive committee of the board. Exer's management team will handle day-to-day operations.

Exer Chief Executive Dr. Cherlin Johnson said at Exer, patients can access emergency room doctors and their expertise without the long wait times and hospital-level costs typically associated with emergency department visits. He said Exer is ideal for people who need routine care outside of normal physicians' office hours, or for those who need a higher level of care than would typically be offered in physicians' offices or in an urgent care facility. For instance, Exer sites can treat complex lacerations; they can provide reduction and splinting for fractures; and they can use IVs to hydrate, control allergic reactions or administer antibiotics. According to information from Exer, the company's sites provide standard urgent care treatments such as X-rays, vaccinations and routine physicals and also provide services that standard urgent care sites normally do not provide: They do workups, including for abdominal pain and atypical chest pain, using their laboratory, ultrasound equipment, electrocardiogram and other equipment. Exer doctors can give preoperative consults to patients who need information fast and for those without a primary care physician, a service not normally provided by urgent care clinics.

Exer's clinics are staffed by board-certified emergency physicians or doctors eligible to sit for those emergency medicine boards, according to Johnson.

Providence and Exer said that Southern California emergency departments are experiencing a surge in patients because about a dozen area hospitals have closed since 1998 and because more people are seeking care now that they are insured through the Affordable Care Act.

According to information from Exer, about 70 percent of people who visit hospital emergency departments do so unnecessarily, since they could receive care in a facility providing a lower acuity of care. Exer said it saves consumers or their insurers over $1,100 per visit, on average, as compared with a hospital emergency department.

rch and Educational Trust and the American Hospital Association partnered to conduct the study. The group has just completed its most recent survey. It will be released later this year.


Copyright © 2016 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.

Copyright © 2016 by the Catholic Health Association of the United States

For reprint permission, contact Betty Crosby or call (314) 253-3490.