Physical and Virtual Care Facilities: The Health Care System

In my last post, we talked about how health care professionals are commonly categorized and what roles they play within the health care system, with those providing direct patient care commonly categorized as "clinical" and those who support clinicians in their care delivery as "non-clinical."

Today, we're talking about care settings—the physical or virtual places patients receive care in. From the standpoint of the health care system, designing and building physical spaces for health care delivery means that there is an ongoing expense obligation to operate such facilities—they need to be staffed, supplied, equipped and maintained, and all of this requires monetary resources and continual investment. Some facilities are simple to set-up and operate—like a neighborhood doctor's clinic—and others are more complex, like a full-service hospital. The type of facility built in a community usually depends on the complexity of the health needs of that community, its operating cost (and the ability to recover that cost, or make revenue if it's a for-profit entity building that facility), the availability of clinical and non-clinical staffing, and whether alternatives to facility care are more feasible or justified (for example, by transporting a patient elsewhere because doing so would be more cost effective than operating a full service health treatment facility, or by using virtual care services, which will be discussed later.)

Let's start with physical spaces and how they connect different entry points within the health care system, starting with a community doctor's clinic (or physician's office.)

Doctor's clinics: A doctor's clinic is usually the first, common point of contact a person has with the health care system, and it's here where preliminary assessments and diagnoses are made, treatments offered, or ongoing follow-up provided if treatment was received elsewhere. If a doctor in this setting, commonly known as a General Practitioner, or GP for short, can't exactly pinpoint the health issue a patient is experiencing, or needs to confirm a diagnosis with a test they don't have the equipment to perform, they will refer that patient for diagnostic imaging (e.g., an MRI or CAT scan) or laboratory service at a hospital or other facility in the community. A doctor can also refer a patient to a disease specialist if a more specific level of expertise is required for diagnosis and treatment, including surgery. The clinic maintains a medical history for the patient, which is then made available to other health care professionals when required. Minor trauma care can be offered here too—for example, if you've managed to cut yourself deeply, you can get stitches at a doctor's clinic. While a certain level of care can be provided by the doctor's clinic, there are no overnight treatment beds, powerful diagnostic equipment, or a broad-compliment of supporting health care staff, which means that if you had a significant injury or were experiencing serious health symptoms, you'll need to go to an emergency room at a local hospital (if emergent) or an urgent care centre (if it's not emergent, but serious.) Doctor's clinics also do not operate 24 hours a day/seven days a week, and for these reasons a facility like a hospital or urgent care centre becomes necessary when you need a more significant level of care.

Hospital: A hospital provides a more significant level of care to patients that can't be offered by a doctor's office or other facility. If serious medical treatment and monitoring is needed—for example, for surgery or when experiencing a significant injury or illness—a hospital has the right equipment and clinical staff compliment to address complex health care challenges on a relatively short-term basis. A hospital has multiple patient care "units" and treatment beds: For example, there are care beds for those who've had surgery, require general medical care, are battling cancer, or are being treated for mental health challenges or drug and alcohol addictions. Because there is a greater compliment of clinical health providers in a hospital, many more diseases and illnesses can be treated. And in addition to having surgical facilities, hospitals typically operate emergency rooms to handle significant illness and trauma cases on a 24 hour/seven days a week basis. Hospitals are expensive to manage and operate, however. And for patients whose care requirements do not need the degree and range of care services offered by a hospital, or if a surgical treatment can be made without an overnight stay, other facilities like an ambulatory clinic or an alternative care facility may be more appropriate to care for patients like these.

Ambulatory clinic: For some medical conditions and treatments, a full-service hospital with overnight beds is not necessary, but the kind of medical equipment required may be. This is where an ambulatory clinic can help. For any "same-day" treatment, for example, cataract surgery or kidney dialysis, an ambulatory clinic will have the right facilities, including a surgical suite, to treat patients, but will have them recover at home as this type of facility typically does not have overnight treatment units and beds. As medical procedures and technologies advance, more health issues will be treated on an ambulatory basis, which means a lesser dependence on using the more costly services provided within a hospital and more comfort to patients who can recover from their medical procedures at home. For some treatments, like kidney dialysis, it’s also more cost effective and faster to be treated in an ambulatory clinic than a hospital. But for some health conditions where more permanent, on-going health treatment is needed on a long-term basis, an ambulatory care centre or hospital may not be the most appropriate care setting for these health conditions. Instead, an alternative care centre is likely what's needed for patients like these.

Alternative care centres: If a patient is experiencing a long-term illness, disability, or other care need that requires a more significant degree of care service, but not at the level offered by a hospital, an alternative care centre is likely the best place for these patients. Alternative care centres have long-term treatments beds and are typically staffed by nurses and other allied health care professionals, with a few on-call physician scheduled visits. Often these facilities host elderly, frail or disabled patients who need a level of care that can't be provided at the home through regular nurse and health care aid visits, and when care received at a hospital on a long-term basis would be extremely costly and ineffective. Alternative care centres are often less expensive to operate than a hospital and offer comprehensive programs to help patients live with difficult health conditions that may not ever resolve completely, but can nevertheless be managed with active and ongoing medical assistance.

Urgent care centres: An urgent care centre can offer care to people when it's otherwise difficult to book an appointment at a doctor's clinic and when a person's health concern is not considered an emergency. Urgent care centres are typically open later than doctor's clinics, often into the late evening, and are partially equipped with hospital grade equipment. They do not, however, operate overnight beds or treat health conditions that are considered an emergency. (In this case, the urgent care centre would arrange for an ambulance to transfer a patient who needs emergency care to a hospital.) Urgent care centres are primarily staffed with doctors and nurses and often operate with the goal to take "pressure" off busy hospital emergency rooms that are sometimes crowded by individuals who, while legitimately concerned and anxious about the health issue they are experiencing, would not be classified and treated as an emergency by emergency room staff, and would be better served by visiting a doctor's clinic if they were able to schedule an appointment. (And often they are not able to, which is why they would go to the emergency room in the first place, if the doctor's clinic is unable to see them for a same day appointment or if the clinic is closed for the day. This is a common criticism of the primary care system.) An urgent care centre provides a point of care between a hospital's emergency room and a doctor's clinic and serves those who are anxious about their health condition and want an opinion by a doctor, but can't see a doctor at their local doctor's clinic and would not be considered a high-priority health case by a hospital's emergency room (which also often entails a long wait to see a emergency room doctor.)

Rehabilitation facility: The last of the physical care spaces on this list is a rehabilitation facility, which serves patients who need to regain lost physical function due to illness (i.e., after suffering a stroke) or traumatic injury (i.e., from a car accident) or who were born with deformities that affect their mobility or their ability to see, hear or speak and where there is evidence that their condition can be improved through clinical treatment. Allied health care providers offer the bulk of care in these settings and the rehabilitation facility has separate care units that offer specialized treatments for these conditions; for example, for hearing, speaking, moving (mobility), thinking (cognition), etc.

Virtual Care Delivery

We’ve learned that there are several physical care delivery spaces in the previous section, but care can also be delivered virtually to you in your own home, between different care facilities, or anywhere else, via the internet. Care delivered this way usually involves computing devices with video and audio capability that are connected to each other via the internet and are located far from each other, with a care delivery professional at one end and the patient at the other. Virtual care is most often delivered when it is otherwise difficult for a patient to travel to receive health care services in person; for example, if traveling to receive treatment or diagnosis would take too long or is otherwise dangerous, or if there is a specific danger to a patient’s health if he or she were to travel. Or, if only follow-up care is needed, virtual care can make it convenient for patients and health care professionals to meet, just not in person. Similarly there are situations where certain specialties within the health care profession can only be accessed in certain places. With virtual care, those specialties can be accessed by anyone anywhere, when needed.

But because there is no physical contact, health services that are delivered virtually are often the kind that presents the lowest treatment risk to patients, just in case a patient’s health deteriorates for some reason while receiving those services. Common health services provided virtually may include: getting a prescription for common symptoms; a first consultation for health care services; a health “check-up” that does not require a physical examination; the discussion of a medical treatment plan; or the receipt of therapy sessions for mental health or otherwise.

Now I offer one caveat when I say that there is “no physical contact”: This is true in most cases when virtual care is being delivered. But with technology rapidly advancing, there are opportunities for clinicians at one end to provide more complex care services to patients through the use of, for example, robotics, where surgery of some type is conducted within facilities miles apart.

Now that’s a good segue to our next conversation, which introduces health care technologies and the benefits and challenges that come with using these technologies when providing care to patients.

The 2019/2020 Harkness Fellowship — A research proposal.

People: The Health Care System