From analytics to execution: Starting a new ambulatory network

Growing amid medical group mergers and the formation of a new ambulatory network entails a lot of work: Removing legacy branding from merged facilities, bringing older spaces up to the new entity’s standardized practices, and even creating new sites of care.

An outdated exam room or two are easy to spot, but assessing the needed change across dozens of care environments across all New York City boroughs and Long Island required a lot of data to manage the vast new network of care built by EmblemHealth, composed of physician groups such as AdvantageCare Physicians New York (ACPNY) and Bronx Docs, community-based “neighborhood care” sites, dental offices and more.

Beth Leonard, chief corporate affairs officer, EmblemHealth, New York, and Wendy Weitzner, FACHE, partner, The Innova Group, Boston, detailed this massive, multiyear project during their session at the 2021 Medical Practice Excellence: Leaders Conference.

“New York City is the most diverse city in the world. … There are more than 800 languages spoken in our service area, with more than half of our patients speaking in a language other than English at home,” Leonard said, underscoring how neighborhood care sites for underserved communities often hire directly in the communities they serve.

EmblemHealth’s relationship with ACPNY is unique, Leonard added, in that they are Emblem’s preferred provider and more than 60% of ACPNY’s patient base is made up of EmblemHealth members despite ACP accepting more than 30 other payers, which makes them a popular choice for care in the neighborhoods served. Part of that popularity comes from culturally and linguistically aligning providers and care teams to each of those communities.

Focusing on what matters: Customer demand and core services

The organizations conducted surveys of current patients and the market to build a new facility footprint strategy. “Quality care became the driving factor of choice, even before convenience,” Leonard said, noting that patients said that experience with a provider was the chief consideration when making decisions about where to get care.

However, patients also noted that they preferred integrated facilities offering multiple services (e.g., labs, radiology, specialists) and the improved communication of medical records being available from one facility to the next.

They soon realized that ACPNY’s specialties were not geographically distributed in a convenient way. Based on customer feedback, ACPNY evolved the care model to focus on three core areas — internal medicine, family medicine/pediatrics and OB/GYN — with eight specialty services and procedures that align with the population health care model (see Figure 2).

“Our new care model became an integral strategic decision early on in facilities strategy,” Leonard said, which helped create a “whole you” coordinated care approach for ACPNY. The integrated care teams include primary care physicians (PCPs), advanced practice providers (APPs) such as nurse practitioners (NPs) and physician assistants (PAs), registered nurses (RNs), and care team staff. “While the initial reduction of services was difficult for some physicians,” Leonard said, “we’ve seen patient satisfaction and physician retention increase.”

The facilities strategy

ACPNY was the result of four different medical groups that merged over time, and the location and sizes of its facilities reflected it, Weitzner said.

“They were often oversized. … There was indeliberate distribution of specialties, so we might have two cardiology practices within blocks of each other and then none for miles,” Weitzner said. “The buildings and space were often obsolete and didn’t support the modern or desired operational practices, and some were also in poor condition with deferred maintenance.”

Weitzner worked with EmblemHealth and ACPNY with the goal of realigning, resizing, redesigning, rebranding and creating new sites of care. With customer feedback in hand, the organizations set to form:

• A delivery system plan (Where should the sites of care be?)
• Space standards and program development (How should those spaces work?)
• A real estate search (Which buildings and parcels are available? What kind of deal structures can be made for those sites?)
• Brand and interior standards (What should care spaces look like to represent the brands and operations?)
• Communications and promotion strategies (How do they let people know about the new care model, new locations and updated facilities?).

Delivery system plan

A delivery system plan, Weitzner noted, boils down to determining how much care should be given and where to provide it, with top-down considerations (e.g., market conditions and overall strategy) pushing against bottom-up factors (e.g., facility conditions). 

That planning begins with assessment of the current portfolio of facilities and building a fact base about the existing exam room capacity, overall square footage, how long leases are in place, accessibility, parking, and the overall patient flow and utilization. These data points revealed varying rates of utilization across buildings and clinical suites. “That’s another data point for us to understand whether this is a building we should stay in, reconfigure or realign,” Weitzner said.

On the top-down side, the system plan needs to be informed by a forecast of patient demand. Simplified down to an equation, Weitzner recommends dividing demand (consisting of demographics, health status, market share and other related factors) by the operational model (e.g., care management, technology, productivity data) to determine the required resources.

“It’s a complex puzzle for an organization that’s a health plan and a physician group and specialties,” Weitzner said, in that they were attempting to find the crossover among EmblemHealth members, ACPNY primary care population and ACPNY specialty patients (see Figure 3). Doing so helped identify leakage of the primary care patients not going to ACPNY specialists.

Understanding the primary service areas was another outcome of looking at the data, with each facility serving a somewhat unique and partially unduplicated set of populations, Weitzner said, who would travel in interesting patterns different than most suburban patients.

“You often use drive time to figure out where something should be, and in a very urban place, driving isn’t really how it works,” Weitzner said, so they considered walk times and public transit availability.

Aiming to have enough productivity to hit the 75th-percentile based on MGMA DataDive, they compared utilization rates from the EmblemHealth data and then compared it against the population and set a benchmark for where to place certain types of providers.

Because some attributes make a specialty more likely to be distributed across areas rather than consolidated with others, the team worked to build a facility hierarchy to avoid any duplicative or operationally inefficient specialty placements. Figure 4 shows an example of a facility hierarchy that lists the types of specialists and ancillary services that work best in certain integrated facilities beyond the core care areas.


Applying that hierarchy to the existing facilities and assessing the broader market allowed them to make informed decisions about which facilities to shrink, expand and renovate, respectively; which facilities to close; which new areas to create facilities; and which types of facilities to add in each market, Weitzner explained.

Space standards and program

While the data laid a great foundation for the work to be done, “the tactical reality is sometimes a lot harder when implementing the strategy,” Weitzner admitted. With a plan for each primary service area, the teams worked to build functional standards to apply to all new buildings in the system around:

• Size, quantity and sharing of exam rooms
• Location, distribution and sharing of procedure rooms and ancillary testing
• Size, quantity, location and sharing of offices, workstations and work rooms
• Roles and location for pre-visit and post-visit processing, registration, check-in, checkout and waiting
• Roles, location and team configuration for clinical support staff
• Scale, roles and location for scheduling, phones and billing staff
• Location, sharing and inventory levels for materials management
• Location, size, sharing/functions of conference/break rooms
• Adjacencies and flow.

In addition to applying these standards to new facilities, Weitzner said that older facilities would be adapted as closely as possible to the new standards. These standards were created with input from operational teams, staff workshops and virtual tours of spaces to understand different approaches to waiting areas, office workstations and more.

Standard space and functional programs from those efforts produced operational concepts for each space in the facilities. For example:

• Private offices for physicians were replaced by a “privacy enclave” — a 55-square-foot space, integrated into care team work areas, to replace older, 120-square-foot private offices.
• A typical exam room was designed for a 110-square-foot space, templated with a standard layout for equipment and case work.
• Post-COVID-19, one site sought to create larger central storage areas for personal protective equipment (PPE), as well as isolation rooms, temporary screening stations and battery backup for vaccine refrigerators. Materials were chosen for cleanability.

Branded environments and design guidelines

With a standardized approach to create better unity and functionality across the care sites, ACPNY also worked to build a new approach to branding the environments.

“Our approach has been comprehensive versus transactional, relying on our knowledge of the neighborhoods to bring to life imagery, colors and other elements that reflect the locality while maintaining an incredibly strong and even increased brand presence,” Leonard said.

The challenge, Leonard said, is maintaining brand consistency across multispecialty areas while still feeling reflective of the unique communities being served. Ultimately, they chose to focus on identified brand drivers (community, convenience, comprehensive care and continuity of care) to influence what types of messages appear (e.g., “whole you,” compassion, wellness) and the specific design attributes within different medical offices (e.g., vibrance, aspirational, inspirational, warmth and comfort). Different locations highlighted unique patient stories, and care team members are featured on photo walls in each office. Design guidelines for items such as wayfinding signs were developed, helping to distinguish various specialties in office directory maps with consistent colors.

“It reinforces our brand at every point,” Leonard said. “Consistency of color and experience, regardless of the location, gives us a branded environment like Starbucks. … We wanted that franchise model.”

“It even led us to a new logo,” Leonard noted, as the desire for modern-looking facilities meant ensuring that the logo evolved to be fresh and fitting with other aesthetics.

Communications and promotion

The extensive realignment of providers, offices, designs and other elements as part of the EmblemHealth/ACPNY network project signaled that it was time for a “total brand realignment and reintroduction” to the market, Leonard said.

This meant a larger investment in the brand presence via paid advertising, featuring a new campaign — titled “Every Part Matters” — highlighting grand openings of new sites and calling special attention to new sites in historically underserved communities. The campaign centered around the notion that the body is a complex and interconnected machine, and that ACPNY’s integration of primary and specialty care offerings were best suited to look after each of those parts (e.g., hands, eyes, heart) to take better care of the patient’s “whole you.”

Conclusion

From 2019 through this year, ACPNY renovated, relocated and/or opened 14 locations that expanded the network’s footprint with new operating models, increased access to specialists, and introduced new interior and exterior branded environments.

The outcomes of that work have included increased Press Ganey scores, a reduction in negative reviews on Google and other online platforms, increased brand favorability and awareness, and a growing patient base and market share.

The efforts also have paid off by invigorating recruitment efforts for providers and staff, as it’s improved the ability to attract talent and give them a sense of pride about serving at the new and updated sites, Leonard said.

Being in the right neighborhoods with the right staff and providers, ACPNY was able to be a primary partner of New York City and the state for providing COVID-19 testing and vaccine distribution in the past year. “Our geographic distribution and space allowed for us, without any change, to isolate patients and serve these communities in need without making additional investments,” Leonard said.