The five key challenges for providers expanding ambulatory care

Topics: Care Models, Clinical Quality, Providers, Hospitals

By Heather Drost, senior editor

Providers increasingly are shifting their focus to ambulatory care—but providers must address key challenges as they move forward, says Ann Scott Blouin, executive vice president of Customer Relations at the Joint Commission.

The push toward ambulatory care has been growing for nearly a decade: American Hospital Association data show total outpatient visits rose from 624 million in 2008 to 675 million in 2012. During that same time period, total inpatient admissions for U.S. hospitals fell from 35.8 million to 34.4 million. And U.S. Census Bureau data show health care spending in the second quarter (Q2) of 2016 increased at the highest year-over-year growth rate since the first quarter of 2015. That growth, according to the data, largely was driven by ambulatory care spending, which rose by 7.3 percent from Q2 2015 and totaled $244.3 billion.

Experts say the growth in ambulatory care services is fueled in part by new value-based payment models and technology advancements. In fact, a 2015 peer60 report concluded that the widespread adoption of electronic health records (EHRs) and an increase in ambulatory care facilities attesting to the federal EHR incentive program are "good indicators ambulatory care is ready for primetime."

5 key ambulatory care challenges

But this shift toward ambulatory care can pose significant quality and safety challenges. Blouin outlined the top five quality and safety challenges facing ambulatory care:

1. Diagnostic errors are more common: Ambulatory patients typically are scheduled for very short appointments: about one patient every 10 to 15 minutes. As such, sometimes "you have to come to conclusions without all of the information," Blouin said. She added, "[I]f the diagnosis isn't accurate then the treatment, of course, would be incorrect."

2. Infection control is more difficult: While hospitals generally know the importance of properly managing, cleaning, and sterilizing equipment, Blouin said the Joint Commission has found that it is an area in which ambulatory care clinics may struggle. Blouin also noted that ambulatory care clinics need to be prepared to respond to infectious diseases. For instance she noted that a patient with a highly infectious disease, such as Zika or Ebola, could just as likely present for care at an ambulatory clinic as a hospital, depending on the trajectory of the disease.

3. Nobody really knows how well ambulatory care performs for some procedures: "Inpatient hospitals quality and safety is pretty well researched, but ambulatory care quality and safety is still a relatively young topic for research," Blouin said.

4. Test results from earlier inpatient stays often go "astray": Blouin explained that, when a physician orders a test during an inpatient stay, the results sometimes aren't acted upon during an ambulatory follow-up—whether because the patient fails to comply with follow-up instructions, the test results aren't communicated to the patient, or the result ends up in the inpatient record instead of the outpatient record.

5. Inpatient and ambulatory EHRs often don't talk to each other: Blouin noted that "in the ambulatory setting … (providers) don't have easy access to the complete medical record." That's because the information often comes from different providers with disparate EHRs.

Driving factors

Despite these challenges, experts believe that ambulatory care's gradual growth rate increases will continue as technology improves.

Robert Berenson, a fellow at the Urban Institute, noted, "People don't want to go to the hospital if things can be performed safely out of the hospital." And technology, he explained, has significantly increased providers' ability to perform procedures outside of hospitals.

Blouin noted that technology has reshaped the industry within the span of her career: "When I first became a RN, nobody would have ever thought of doing a hip replacement or knee replacement" outside of the hospital. But today those can be done as outpatient procedures for uncomplicated patients with low risk factors.

"Technology and the advances of science has continued to help to move things to outpatient," Blouin, adding, "I do believe there will continue to be some slow but incremental growth in ambulatory."

Want to learn more?

To learn more about the strategies health care providers can use as they transition to ambulatory care models, join Blouin for a webconference on Thursday, Oct. 20. She'll detail additional challenges emerging in ambulatory care, transitions of care and care coordination, and several strategies for health care teams to consider as they move forward.