Healthcare leaders are developing outpatient strategies that enhance access in an increasingly risk-based environment. This can happen by several means—through acquisitions, partnerships, building new facilities, and often through some combination thereof. From there, the possibilities are almost endless.

This article first appeared in the July/August 2016 issue of HealthLeaders magazine.

To thrive in today's healthcare marketplace, hospital and health system leaders need to think beyond putting "heads in beds."

For some, fulfilling the goal of providing patients with the right care at the right place at the right time means becoming virtually omnipresent in the daily lives of consumers and potential consumers.

Expansion of ambulatory and outpatient care networks makes sense for several reasons, including the desire to improve patient access, strengthen patient-provider relationships, and increase revenue. In fact, 84% of healthcare leaders who responded to the 2015 HealthLeaders Media Ambulatory and Outpatient Care Survey regard the industry's shifting focus from acute to ambulatory care as an opportunity rather than a threat.

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Getting the Value Out of Postacute Care

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This figure is indicative of a changing mindset among health executives about outpatient business, including ambulatory and postacute care.

"Historically, we have viewed ambulatory and postacute care as means to support hospitals," says Scott Nordlund, executive vice president for growth, strategy, and innovation at Trinity Health, a Livonia, Michigan–based not-for-profit with facilities in 21 states and annual operating revenue of about $15.9 billion.

"As we wade into the world of population health and begin to think about networks of care—including outpatient ambulatory networks—in many cases, we're investing as much there as we are in our inpatient facilities. Not everything is necessarily centered around the hospital," he says.

Maintaining network adequacy
Redrawing one's circle of influence can happen by several means—through acquisitions, partnerships, building new facilities, and often through some combination thereof. From there, the possibilities are almost endless, encompassing every type of outpatient care from extensivist clinics to walk-in care to telehealth.

"As we wade into the world of population health and begin to think about networks of care—including outpatient ambulatory networks—in many cases, we're investing as much there as we are in our inpatient facilities. Not everything is necessarily centered around the hospital."

To that end, Trinity Health has recently completed several projects to bolster its outpatient presence, including a network of freestanding emergency departments, an integrated medical fitness facility in Ohio, the acquisition of home health agencies throughout the United States, and more.

And there's more outpatient growth on the horizon, including several physician practice acquisitions in key markets and even conversion of some inpatient hospitals into outpatient destination centers.

Much of Trinity Health's strategy comes down to maintaining network adequacy, says Nordlund. "You have to have sufficient access points across your market and the right kind of levels of care, from the more traditional inpatient space through the outpatient ambulatory as well as postacute spaces in order to care for a population."

Trinity Health is far from alone in its quest to improve population health through outpatient growth. That was among the top factors driving outpatient strategies, cited by 43% of HealthLeaders Media Ambulatory and Outpatient Care Survey respondents.

Other priorities for outpatient expansion included improving quality outcomes (52%), expanding market share (50%), increasing revenue (48%), responding to consumer-driven trends (43%), and reducing costs (39%).

Understanding physician organizations
To achieve these goals, roughly half of the leaders surveyed reported partnering with, acquiring, or establishing physician organizations. But doing so isn't necessarily simple.

"You have to have sufficient access points across your market and the right kind of levels of care, from the more traditional inpatient space through the outpatient ambulatory as well as postacute spaces in order to care for a population."

Nordlund says he learned many lessons throughout Trinity Health's outpatient expansion, but the need to appreciate the uniqueness of each setting is one that stands out. "The expertise that it takes to run and have well-managed acute operations—those skills don't necessarily translate to what it takes to run a network of care," he says. It requires "learning new skills in terms of how to put together real-estate deals, how to acquire physician practices in a meaningful way, and how to aggregate those practices into well-performing networks."

For health systems, the trick is to assess outpatient opportunities in a strategic, proactive manner, rather than a reactive one, says James F. Kravec, MD, FACP, executive vice president and chief clinical officer for Mercy Health Youngstown, an integrated health system employing more than 6,000 and serving four counties in Northeast Ohio. MHY is one of eight regions of Mercy Health, a 23-hospital health system serving Ohio and Kentucky, with assets of $6.1 billion and net operating revenue of $4.5 billion.

"We have found that locally and nationally, many groups are acquired when there was no other option or when there was a need on behalf of the practice," he says. "I think we've found that the best way to acquire a medical group is to focus on when there's a hospital strategic need and making sure you continue on the mission and strategy of the hospital by focusing on what you're focusing on. Don't change it to fit one practice, because that's where you make mistakes."

A common mistake healthcare organizations make is acquiring practices of poor cultural fit, and MHY is no exception. While past mismatches were clear from the beginning, Kravec says in retrospect, the acquisitions proceeded nonetheless.

"This was a very challenging time for the operators and administrators, as the lack of cultural fit bled down to every aspect of the practice, and the relationships did not survive more than a few years," he says.

As a result of three to four successful primary care practice acquisitions in each of the past three years, MHY has more than doubled its number of employed physicians, from 50 in 2012 to 115 in 2016.

Each of these strategic acquisitions has been part ofMercy's overall strategy for population health, amazing patient care, and organizational growth, Kravec says. In particular, the group is striving to increase its percentage of primary care physicians relative to specialists. To date, its physician composition includes 42% primary care physicians and 58% in specialties.

The physician enterprise is steadfast about staying on course. "It's not meant to be one where physicians have no other options, and we're the last people they called. We want to be very strategic in the practices we acquire."

To help ensure acquisitions meet MHY's strategic alignment, market, and access goals, the group uses a matrix that categorizes physician practices by three key elements: critical strategic alignment, compatible cultural fit, and capable performance. Depending on how well practices score in these categories, MHY will rank them by worthiness to pursue, consider, consider exclusively for succession planning, or avoid.

Assessing the objective criteria within these categories is fairly straightforward. Some of the easy questions: How many active charts per FTE? What's the wait time for a new appointment? Is the group aligned with a competitor? What brand and type of EMR does it use, if any?

"The tougher ones are reputation and quality metrics for those that are not in a hospital setting," says Kravec. "If a physician is in a private practice, it's a little harder to find some of this data, so we have to use our best educated knowledge of the practice to fill out the matrix."

Other considerations are related to geographic expansion potential, the ratio of primary care physicians per population in a given area, and the number of retail or open access clinics within a certain radius.

From the first meeting with potential recruited physicians, including those coming out of residency, leadership communicates its goals and expectations for improving population health. The group is focused closely on the same six primary-care quality metrics as Mercy Health at large, which are systolic blood pressure, hemoglobin A1C, neuropathy screening for diabetics, breast cancer screening, colorectal screening, and pneumonia vaccination.

"When practices come on board, they know from the beginning that we're going to focus on population health and hitting our benchmarks for the metrics that we're following," Kravec says.

The power of partnerships
In addition to acquisitions, strategic partnerships can also help health systems expand into the outpatient space; but not all such relationships are created equal, says Nordlund.

"In these spaces, partnerships make a lot of sense," he says. However, "you want to have a very well-defined set of criteria that you think about and use when choosing best-in-class partners that you want to be with, because whether you hold majority or minority share, that relationship becomes part of your reputation."

One partnership that has been an important part of Trinity Health's strategy for consumer engagement and organic growth is its work with Sharecare, a Web-based patient-engagement tool that provides users with its health risk assessment, individualized wellness programs, fitness device data aggregation, facility locators, appointment schedulers, secure messaging with physicians, symptom navigator tools, and more.

"Strategic partnerships are important to our 2020 People-Centered Strategic Plan," Nordlund says. "We are business partners with—and equity investors in—Sharecare because we believe they are well-positioned to help us engage patients and consumers in a way that helps us build the strong, lifelong transformative relationships we need to build in order to deliver truly effective people-centered care."

So far, the results of the initiative have been impressive. Since the first pilot sites went live on Sharecare in October 2015, there have been more than 2 million visits to Sharecare in those pilot markets, Nordlund says, adding that visits to Trinity Health physician profiles and content on Sharecare.com has grown by 83% from February to April 2016. "We are very pleased with the value and intellectual horsepower Sharecare is bringing to our partnership.

"We're moving ahead with strategic opportunities and testing right now, and are looking forward to assessing our metrics after all the levels of our effort are implemented, especially when it comes to integration with our patient portal," Nordlund says.

As with any aspects of the outpatient movement, such relationships require leaders to think differently than they have in the past—when hospitals owned and controlled most parts of the delivery of inpatient care.

When it comes to aligning oneself with others' expertise, and in turn giving up some measure of control, healthcare leaders should consider carefully who their partners are, how they reflect on their organizations, and the plan of action if there is a problem, Nordlund says.

"These are not vendor relationships. These are true partnerships, so it's really important to think through what that means to you well beyond just return on investment," he says.

In other words, while a vendor-buyer relationship is primarily about a sale and purchase of products and/or services, a partner becomes part of the fabric of your organization and affects how services and even care may be delivered, Nordlund says.

"Trinity Health partners with all kinds of organizations in many different ways, and each partnership is unique," he adds. "The major difference with the Sharecare partnership is that we are an equity investor in Sharecare and they have accepted accountability for helping us achieve our long-term goals in consumer engagement."

Evolving partnerships
In some cases, relationships evolve over time.

For example, Henry Ford Health System, a five-hospital integrated nonprofit health system in Detroit with $4.7 billion in annual revenue, is among many organizations that developed early partnerships with CVS MinuteClinic in response to the growing retail health sector. Under its original 2011 contract, Henry Ford provided physician medical directors exclusively to CVS MinuteClinics in Detroit to ove see clinical operations and supervise nurse practitioners.

While Henry Ford still provides the medical directorships, the rules are more flexible so as to benefit both parties. "At one time it was a very exclusive arrangement, but it actually put handcuffs on everybody," says Paul Szilagyi, Henry Ford's vice president of primary care and medical centers.

Those restrictions not only locked Henry Ford physicians in with CVS, but the Henry Ford branding also limited CVS' ability to receive patient referrals from other health systems. Loosening those ties also allowed Henry Ford to create and run its own retail clinics, including QuickCare.

"We view that the future of healthcare is going to be more and more about outpatient services, so we've intentionally been trying to add new outpatient centers and make sure we have a strong outpatient network throughout the region that we serve."

Meanwhile, the two organizations continue to collaborate in significant ways. "We are actively talking with them right now about how we can work together on understanding our populations better to improve adherence to medications and protocols, and then to also bring down the cost of care at the same time," Szilagyi says.

MinuteClinic's recent switch to the Epic EMR system has made population management and care coordination easier for Henry Ford providers, he adds.

Primary care at the center
Outpatient expansion is also a priority for Cleveland-based University Hospitals Health System, an integrated network of 18 hospitals with more than 40 outpatient health centers and primary care physician offices in 15 counties throughout Northeast Ohio.

"We view that the future of healthcare is going to be more and more about outpatient services, so we've intentionally been trying to add new outpatient centers and make sure we have a strong outpatient network throughout the region that we serve," says Paul Tait, University Hospitals' chief strategic planning officer.

And not unlike its fellow Ohioans at Mercy Health, some 70 miles away, University Hospitals regards primary care as the hub to its enterprise.

The system's emphasis on primary care and population health began in 2010 when the team, led by Tait, recognized the need to become a market leader in delivering accountable care. By the end of that year, University Hospitals developed an accountable care organization for its own employees and added a pediatric ACO in 2012. Building on these efforts, the organization has since added a Medicare Shared Savings ACO and entered into ACO contracts with several payers, including Anthem, Cigna, and others.

"So all told, when you add up all the various types of ACOs, we have over 300,000 lives that we manage now," says Tait.

What's more, a total of five hospitals have joined the University Hospitals system within the past two years, which in many cases included the absorption of existing outpatient centers. While some of these facilities help support the growing network, the organization is on the lookout for remaining community need.

"We believe in the importance of outpatient services, so what we've been doing is strengthening the current sites and adding new ones," Tait explains.

For example, Elyria and Parma Medical Centers are two hospitals that became wholly owned parts of the UH system in 2014. Set to open this summer, UH's Broadview Heights Health Center, located south of Cleveland, has been designed to integrate with them by offering on an outpatient basis a range of primary and specialty care physicians (cardiology and orthopedics), laboratory services, diagnostic imaging and radiology services, as well as emergency and urgent care.

A similar 50,300-square-foot ambulatory health center and freestanding emergency department under construction in North Ridgeville, about 20 miles west of Cleveland, will in 2017 support the system's west-side hospitals: Elyria Medical Center and St. John Medical Center.

While the size and shape of each new location may vary, they share a common denominator. "Our whole model is around primary care physicians," says Richard Hanson, president of University Hospitals' community hospitals and ambulatory network. "So we don't build a site until we have a large primary care mix in that location, and then we bring the specialists out to that site where our primary care physicians are already located."

Even still, leaders are careful to assess demand before placing physicians anywhere, particularly for specialists, says Hanson. Some outpatient centers, as a result, include timeshare suites in which each specialty physician might work two days per week, and work out of other centers the remaining days. "That way you're offering services locally but you're also keeping the physician productive in terms of how time is used," he says.

University Hospitals physicians are also grouped strategically to allow them to cross-cover for one another and share evening and weekend call coverage. They all share the same EMR as well, which the team regards as a must for coordination of care.

And as consumer-driven healthcare continues to take hold, patient convenience is also important. "Consumers want convenient access to primary and urgent care," says Tait. "So we try to provide as much care locally as possible, because we recognize that most people don't want to get in the car and travel very far for care if they don't have to."

Today's consumers also want choices, notes Hanson. So in some cases, the system offers urgent care and an emergency room in the same facility. "If it is a true emergency, they can go one avenue, and if it's an urgent-care-type need, they can go the other way and keep the cost down," he says.

To help consumers determine which setting is most appropriate—and get seen as quickly as possible—University Hospitals uses the InQuicker program. The technology allows patients to log in through the website or mobile app, answer a brief series of questions to determine the appropriate site of care, and self-schedule an appointment at the ED or urgent care center that is closest to them or has the shortest wait. Typically, patients who use this technology can be seen within 10 minutes, says Hanson.

InQuicker has benefited University Hospitals as well, through increased urgent-care volumes and fewer nonemergent cases showing up in the ED, Hanson says. Based on registration data dating back to January 2014, 46%–50% of patients who used the program indicated they were new to the facility they visited, and thus represented 552 new patients in 2014, 3,698 new patients in 2015, and 2,159 new patients between January and May 2016.

When an outpatient growth tactic is successful, the volume speaks for itself in indicating the system is offering the right services in the right locations to meet community need, Hanson says. "These are our entry points into our system. So if they're run well, they feed our hospitals and facilities."

The benefit of a large health system with various facilities throughout the region, Tait says, is that patients have the ability to get most care closer to home, and on an outpatient basis when that makes the most sense. For instance, while UH's main campus provides high-level tertiary care for complex cases, oncology patients are able to access much of their care close to home at the UH Seidman Cancer Center's outpatient locations.

In general, UH outpatient facilities often service patients who, at some point, will be seen in a UH inpatient facility, Hanson adds. And while adding an outpatient location does boost system net revenue and market share in areas previously lacking access, lag time to break even can vary considerably by project.

'Radical convenience'
Meanwhile in Detroit, Henry Ford Health System has designed much of its ambulatory strategy around a concept its leaders have dubbed radical convenience.

"We started as a hospital, but we were fast in moving from inpatient care to outpatient care with our vast ambulatory network in this Detroit market," says Szilagyi. "We're constantly looking for new ways to appeal to a more outpatient or ambulatory type of care that is delivered in new ways. It revolves around the idea of access."

That access is available in three ways, which the system's leaders refer to as call, click, or come in.

These catchphrases aren't just about marketing, however. With about 70% of its payer contracts involving risk, Henry Ford is especially attuned to managing population health. And a key part of that strategy is offering care that's not just convenient but also affordable.

"When we first started this adventure, there were only two ways to get into the Henry Ford Health System," he says. "You booked a visit in a clinic or you came in through the emergency room. What we've done is created more opportunities for patients to access the system."

As the "call, click, or come in" terminology implies, some forms of patient care are just a phone call away, via Henry Ford's 24-hour nurse hotline or its cold and flu hotline, both of which are available for free to established patients. For needs that can't be fully satisfied by phone but don't necessarily require an in-person visit, Henry Ford offers virtual visits through its partnership with Teladoc.

And when "coming in" is warranted, patients have plenty of options, including same-day appointments at primary care clinics, three freestanding emergency rooms, four urgent care clinics, and five walk-in clinics located throughout the city.

Henry Ford's newest addition to this array of access points is its QuickCare Clinic, which opened last summer in downtown Detroit. The 2,000-square-foot facility offers retail-focused care that is broader in scope than a typical CVS MinuteClinic, Szilagyi says. Nonroutine services offered include acupuncture, massage, and travel medicine.

While insured patients can go to any of these sites for an office-visit copay, pricing is standardized and posted on a menu board for those paying out of pocket.

In addition to its affordability, Henry Ford utilizes self-scheduling technology to save patients time. Similar to the InQuicker program offered by University Hospitals, Henry Ford holds a partnership with vendor Clockwise.MD. "It's like call-ahead seating so you can reserve your spot in line," Szilagyi says.

Henry Ford was among the first healthcare organizations in Michigan to use Clockwise.MD, Szilagyi says. And with very little promotion, almost 25% of the system's walk-in patients are now using the service. "It's been phenomenally successful," he says.

The other benefit of the technology, which informs patients of the wait time at each nearby site, is that it helps distribute workload throughout the facilities. "It reduces the big waves that roll in at 3:30 when school lets out or at 5 when people get out of work."

As for the financial success of the care sites themselves, leaders will be happy if the QuickCare Clinic breaks even. They expect a learning curve in determining what patients want in terms of the new endeavor, but volume is already on a steady increase.

Overall, the success factors for any Henry Ford site include its abilities to attract new patients to the system and connect care to the people in the system. "Our goal is to help increase the value of care to our patients from multiple perspectives," he says.

"For example, consider somebody who just never bothered establishing a relationship with a health system or primary care provider. If we can meet their needs at a local level, at a low-acuity point, as their needs progress over time and they establish a relationship with us, we hope that they'll think Henry Ford when they need a higher level of care," Szilagyi says.

Knowing your audience
Despite the growth of the retail health segment of the outpatient market, providers face challenges to offer the scope of services patients want within the constraints of the model, which was built around the idea of handling low-acuity, acute medical needs, typically with a staff of nurse practitioners.

Now that major retailers, including Walgreens healthcare clinics, are expanding services to help consumers manage chronic conditions, healthcare leaders must reassess what it means for their system to offer the right care at the right place at the right time.

For Henry Ford, that's somewhat a work in progress. "Clearly, we're working on refining the model and understanding patients' needs a little bit better. Our plan is to actually produce more of these QuickCare Clinics, as we understand the appropriate locations to place them," Szilagyi says.

Though careful not to overgeneralize, he notes that young professionals represent the main demographic drawn to the downtown QuickCare. And while these millennials are less interested in having a relationship with a primary care physician, the system has learned, they are also interested in a place to get care quickly and conveniently near home or work, which the QuickCare site is for many of them.

As a result, staff at the clinic don't push patients without a primary care physician to get one. "That's one of the things we found that's a little bit different for us," Szilagyi says. "With a strong brand name like Henry Ford, people don't think of us as a small retail clinic. So what we're doing is adding PCP services to the site."

Although it can be difficult to achieve direct ROI on PCPs in a retail setting, the same can be true of primary care in general, he says, referring back to Henry Ford's deep investment in value-based care. "In risk contracts, we're taking care of the whole patient."

No model can be one-size-fits-all, Szilagyi says. "To be able to offer a variety of access points in a variety of ways is a key initiative for us."

Tackling financial hurdles to population health
Another strategy some systems have used to provide an array of health services within the communities they serve is with the concept of medical plazas.

Though the definition may vary throughout the industry, for Novant Health—a nonprofit integrated healthcare system serving 4 million patients annually throughout Virginia, North Carolina, South Carolina, and Georgia—a medical plaza can be any collection of services that are provided in a patient-centric and convenient manner in a specific geography.

For the $3.8 billion system, these collections often co-locate a small (30–50 bed) acute care hospital with a variety of ambulatory services such as primary care and specialty offices, imaging, labs, and more, typically not far from existing shopping areas or greenways.

For example, Novant Health Clemmons Medical Center, its 13th medical center, opened in April 2013 as a two-story, 35,000-square-foot facility offering emergency, imaging, laboratory, and surgery services. In December 2014, Novant added a primary and specialty care medical office building to the campus, and further developments are underway.

"The real key is moving away from the concept of a big downtown megahospital into integrated healthcare delivery centers," says Stephen Motew, MD, senior vice president for physician services for Novant Health's greater Winston-Salem area, and a practicing vascular surgeon.

"The importance of this is not only patient centricity and ease of access, but it also allows us to offer lower-cost venues of care," he says. "When we set up things inside hospitals, they tend to be more expensive, and we are really trying to touch on all aspects of patient-centric thinking, which includes affordability."

And like many health systems, Novant's outpatient growth strategy ties directly to its approach toward population health and value-based care.

"If we define this as improving the value delivered to patients—high quality in a more affordable fashion—it's the right thing to do and our payers are supporting this, and the government payers and the patients as consumers are needing this," Motew says. "What we feel is a key factor that drives up cost for the large general population is the inability to access appropriate levels of care."

Quite often, the right level of care is, indeed, found in the outpatient setting, and perhaps of rather low acuity. To address minor health matters quickly, patients can also visit a Novant Health Express Care, several of which are located in strip-mall-type settings throughout the system's markets.

On the more serious end of the acuity spectrum, Novant is also among the growing number of systems developing extensivist clinics at its community-based hospitals to help patients who would traditionally require an inpatient stay from being admitted. A patient with a skin infection, for example, would visit the clinic during the day to have wound treatment and antibiotics monitored. If all is well at the end of the day, these would-be inpatients leave to go sleep in their own homes and return for more hospital-level care in the morning.

"It's a big patient pleaser," Motew says. "It's very effective clinically and tends to avoid the more expensive long-term hospital stay."

"We are seeing appropriate growth that matches our expansion. As we expand our number of providers and access to them, we see a direct correlation in growth in encounters, which has been consistent in the last two to three years."

As a result of these measures, Novant is ahead of its financial goals, according to Motew, with the caveat that a lack of standardized reporting makes outpatient market share difficult to measure.

"That being said, we are seeing appropriate growth that matches our expansion. As we expand our number of providers and access to them, we see a direct correlation in growth in encounters, which has been consistent in the last two to three years."

Nonetheless, Novant is in company with many other systems challenged by the industry's drawn-out transition from fee-for-service to value-based care. "The contribution margins in general for outpatient care compared to acute care are much less in the fee-for-service realm," Motew says. "So we're sort of straddling that chasm between fee-for-service and value, and as our value-based payments increase, we're expecting to see a better matching of that of [outpatient revenue] compared to acute care revenues."

Not being able to predict exactly when payer models will sync up with emerging ways of delivering care poses strategic risks, he says. "For the most part, we're still 85%–90% fee-for-service, yet we're trying to move quickly. So the real challenge is the timing of this. How fast or how slow should we go?"

In the meantime, consumer demand doesn't wait. "We have to be able to respond quickly to consumers, as they're driving a large portion of this. They're telling us what they want, so that's not a challenge, but it's one of our goals."

The business of health
If there's one thing today's consumers consistently say they want, it's one-stop shopping. The outpatient endeavors of Main Line Health, a 1,387-bed health system with $1.4 billion in annual operating revenue based in Bryn Mawr, Pennsylvania, epitomize that concept and more.

"Main Line Health has a long-standing commitment to bring resources into the neighborhoods where our patients live, and to take services that don't need to be in a hospital setting out into the community," says Lydia Hammer, MPH, the system's senior vice president of marketing and business development.

"We have to be able to respond quickly to consumers, as they're driving a large portion of this. They're telling us what they want, so that's not a challenge, but it's one of our goals."

This commitment is reflected in a new vision statement the system is writing as part of its strategic plan. "We don't believe we are just in the hospital business, nor do we believe we're just in the healthcare services business," Hammer says. "We believe we're in the health business, which means our obligation is to help our communities stay healthy; but then if they need us at times of illness or injury, we are here for them."

In carrying out that vision, Main Line Health has opened four major health centers in the greater Philadelphia region. One of the more recent examples is Main Line Health Center at Exton Square, which opened in January 2014. The 32,000-square-foot, state-of-the-art, patient-centered outpatient facility located at the upscale Exton Square Mall features primary and specialty care along with laboratory, imaging, and radiology services, plus evening and weekend hours and complimentary valet parking.

Overall, these outpatient facilities are highly utilized and gaining new patients daily, Hammer says. "For instance, within the first year, the urgent care component of our Exton office grew to see approximately 30 patients a day." The urgent care center within the Main Line Health Center site in Broomall opened in May, and in just over two weeks the site was already seeing an average of 19 patients a day.

Once patients enter the system through these sites, they frequently become long-term patients in other parts of the system, whether through follow-up with Main Line Health specialists or by connecting with primary care physicians to become their regular source of care, she says.

And set to open in winter 2016 is a fifth center in Concordville. The new center under construction will fill three stories and 135,000 square feet. The expansive space will not only include physician offices and high-tech ancillary services but also a medically supervised fitness center and pool, an urgent care center, and café where only heart-healthy food is served.

"A unique element of the Fitness & Wellness Center is that members will have individual and group programming to meet their specific medical needs, such as diabetes, obesity, heart disease, and orthopedic issues," says Hammer.

So far, Main Line's foray into the fitness space is garnering enthusiasm, with more than 1,300 Fitness & Wellness Center memberships sold as of March, well ahead of target, and a surplus of physicians eager to be part of the fitness center's medical advisory board.

If the venture is a success, Main Line will consider adding more fitness centers where community needs dictate, Hammer says. The organization will evaluate its results based on both improvements in patients' health status—which bodes well for the industry's movement toward population health—and old-fashioned utilization data.

Ultimately, "as patients appreciate that Main Line Health is their partner in maintaining their health, we will have a greater impact on the communities we serve," Hammer says.

In addition to facing many of the other outpatient-growth challenges illuminated by systems throughout the country, Hammer points out that long-term patient loyalty is not guaranteed, at least not in Philadelphia.

"It's a pretty heavily resourced market. There are a lot of doctors. There are a lot of outpatient centers. You can get an x-ray pretty much on any corner. So we have to provide a better product, and that means we have to be easier to do business with and demonstrate the high quality of our services," she says. "We have to always provide outstanding quality and have people feel like we exceeded their expectations."

The 'work before the work' builds trust between clinicians and patients, allows more leeway to get difficult conversations right.

As part of their quest to deliver a better patient experience, healthcare providers have been placing greater emphasis on clinicians' communication skills.

The result has been better awareness and training, but there's still work to be done.

"We still have large gaps to close," says William Maples, MD, executive director and chief experience officer of the Institute for Healthcare Excellence and the chief medical officer at Professional Research Consultants.

Prior to launching the IHE, Maples was senior vice president and chief quality officer at Mission Health in Asheville, NC, and spent 25 years as a practicing oncologist and quality leader at the Mayo Clinic in Jacksonville, FL.

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Related: Cleveland Clinic's Experience Chief Shares Lessons in Communication

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"From the perspective of a profession that faces delivering difficult news frequently, I would say that even in situations where there's an opportunity to practice, time and again there are barriers that make it difficult actually executing conversations, especially those involving end of life or palliative care, for a variety of reasons," he says.

The following transcript has been lightly edited.

HealthLeaders Media: What are the fundamental communication skills most important to talking about difficult subjects?

Maples: There are several competencies involved, including finding the right setting to have the talk and recognizing and responding to the emotion in the room.

One of the most critical steps is the "work before the work."

Often there is some lead time to prepare a family and patient in terms of what news may be evolving. And the way you do that prework can make the actual conversation much more productive, helpful, thoughtful, compassionate, and empathetic.

HLM: Which training methods are most effective in helping clinicians improve their communication skills?

Maples: While some online programs can be helpful, they're really not sufficient.

Even if they incorporate some skills-based practice, the online experience is far short of an in-person, skills-based curriculum in which physicians work with physicians and learn from one another.

By far and away, the most effective is an experiential learning model where there's some time for reflection on the importance of getting this conversation right.

HLM: Surely in real life, clinicians don't always get it right. How can they recover from important conversations that don't proceed as hoped?

Maples: There's not a moment in a caregiver's day that something couldn't go wrong.

The risk doesn't just surround having a difficult conversation or delivering bad news, but around everything a clinician does every moment of every day.

One needs to incorporate all of the practices that help clinicians recover when things go wrong or are misinterpreted, and they have lots of chances to practice building resilience to come back and have a correcting conversation or take a correcting action.

Ultimately, it comes back to the work before the work. [That means] having an emotional, psychological bank account filled up so that there's room for forgiveness, there's room for self-awareness on the clinician's part, and there's an opportunity to revisit that conversation with the patient and family.

To be honest, if you've done your work before you actually have the conversation, patients will give you not only a second opportunity, but a third and fourth, as they know that you really care.

HLM: What can healthcare leaders do to support clinicians' development in handling difficult conversations?

Maples: Administration and leadership need to understand what the ramifications are if we don't get this right.

That includes consequences from the errors we create to lack of partnership with patients to deficiencies in safety, efficiency, outcomes, and ultimately the culture of the organization.

The second thing is to recognize that there is a return on investment that comes from creating trust within the medical team, reducing turnover rates, reducing malpractice claims, increasing patient satisfaction, you name it.