Tomorrow’s medical practices will have to accommodate the over-age-65 crowd. Are you ready?
They’re coming to a doctor’s office near you. They’re the Baby Boomers. More than 75 million of them. The fact that people over age 65 visit doctors about 45 percent more than those in the 45-to-64-year-old bracket means physician offices may be overflowing with them in the not-too-distant future. Are the doctors ready? For that matter, are Journal of Healthcare Contracting readers ready? After all, as more hospital systems acquire physician practices, contracting executives will be charged with making sure those offices are equipped for tomorrow’s patients.
Physician practices have had years of experience dealing with such issues as the Americans with Disabilities Act. Bariatrics is another issue with which they’re probably familiar. And while it’s true that accommodating the over-age-65 crowd involves many of the same issues as dealing with the disabled and the obese, the fact is, this segment of the population presents unique challenges. The needs of the elderly are disparate, and the cost to transform an office can be steep, if you’re talking about changing exam room sizes, parking lot arrangements, etc.
But neglecting to adapt their physical space and processes to accommodate the Baby Boomers isn’t a good option for most practices. Patient throughput – and hence, revenues – could suffer, according to experts.
Heterogeneity is challenge
Victor Hirth, MD, MHA, CMD, FACP, is the medical director, geriatric services, for Richland Memorial Hospital, Columbia, S.C., as well as medical director of LifeCare Center of Columbia, a long-term-care facility. “The major challenge for medical offices [trying to accommodate the elderly], as opposed to, say, pediatrics, is this: In the absence of disability, healthy children are pretty uniform in terms of their capabilities. But the heterogeneity among older people is tremendous.” Hirth is also a member of the American Geriatrics Society’s practice management advisory board.
Hirth’s practice, for example, sees patients who are legally blind, who need the assistance of electric scooters or wheeled walkers, and who suffer from memory loss. Some come to the office by themselves, others are accompanied by four family members. “How do you accommodate that spectrum of patients?” he asks. Flexibility in an office’s design elements can help.
Experts agree that physicians seeking to equip their offices for older patients need to focus on a few things:
- Parking has to take into consideration seniors’ more limited mobility.
- Wayfinding is a big issue, both outside the office and inside it. That’s why signage is important.
- Lighting must be bright but with minimal glare.
- Seating throughout the office must be safe (e.g., chairs should have arms, be tip-resistant, etc.).
- Waiting rooms and exam rooms must be big enough to accommodate assistive devices (wheelchairs, walkers, etc.) as well as a family member or two…or three or four.
The three Cs
Cynthia Leibrock, MA, ASID, Hon. IIDA, founder of AgingBeautifully.org, and a consultant and advocate for senior citizens, believes that healthcare facility planners should keep in mind older peoples’ three priorities: control, companionship and contribution. She calls them the “three Cs.”
Control. Senior citizens need to feel in control and secure, says Leibrock. Plenty of windows, affording a view of the outdoors, are a good way to keep them oriented. A well-lighted parking lot is important. Planners should also consider outdoor seating, so seniors can wait in comfort for their ride. A covered entryway can offer protection and security for seniors coming into the office building. The office should also provide a place – perhaps lockers – for patients to secure their coats or umbrellas.
An office whose décor matches the geographic area in which it is located – e.g., the Southwest or New England – can help older patients feel they’re in the right place, continues Leibrock. Finally, seniors value continuity in the people with whom they interact. To that end, the office should strive to have the same receptionist, billing person, physician, nurse, etc., work with the older patient on each visit.
Companionship. Medical offices must accommodate the caregivers of older patients. “You’re designing for the whole family, not just the older person,” says Leibrock, speaking to architects and medical office planners. Is seating available in the waiting area next to the space reserved for wheelchair users? Can chairs be grouped together, so families can converse in the waiting room? Yes, exam rooms should be designed to accommodate extra visitors. But when that’s not possible, the office should consider building out a consulting room, where the physician can sit with the patient and family to discuss diagnoses, treatment plans, etc.
Even bathrooms should be designed with the family in mind, says Leibrock. Family bathrooms (as opposed to men’s and women’s) allow a caregiver of the opposite sex to accompany the patient into the bathroom, in case assistance is needed.
Contribution. “You have a teachable moment” when older patients are at the doctor’s office, says Leibrock. The lesson? Teaching older people how to contribute to their own healthcare. The office should consider providing Internet access in the waiting area, so patients and caregivers can research their disease state, disability or new diagnosis. A lending library, which offers books or videos, is another possibility. “You can even offer [patients] access to their own medical records.” By doing so, the office invites the patient to get more involved in his or her healthcare, and to bring to the attention of the practice any mistakes that might be in the record.
Re-evaluating medical delivery
Redesigning the medical office for an elderly patient base is very much on the mind of Jim Colburn, director, facilities and property, Marshfield (Wisc.) Clinic. Marshfield has 48 clinics in central, western and northern Wisconsin, and “has grown exponentially” over the past 10 to 15 years, he says. “We’re undertaking a 12-month planning process, and at the end, there will be significant remodeling.”
The Clinic is evaluating nothing less than the way it delivers medicine, and its decisions will affect its office buildings. For example, should the Clinic be “organ-based?” In other words, should all cardiac specialists, for example, be in one place? Or should the Clinic group specialists by disease state – e.g., all those who deal with oncology, or musculoskeletal disorders. “After we answer some of those broader questions, then we can get down to what the waiting rooms should look like, what the reception desks should look like,” etc., he says.
Accommodating elderly patients begins long before the patient sets foot inside the exam room, says Colburn. Consideration must be given to how the patient gets from his or her house to the city in which the clinic is located, and then to the facility itself, he says. Then it’s a question of how they park their cars, how they get to the reception desk, etc. “Our largest facility is a bit over 550,000 square feet,” he says. “It’s intimidating. We have to make sure that there is integrated signage and wayfinding every step of the way, so [older patients] know how to get to the campus, the building, the floor and the desk; and then, after the appointment, they have to do it all backwards.”
Parking is a big consideration for the medical office, says Hirth. That’s especially true for clinics or outpatient centers located on hospital campuses or in congested areas. But parking needs to be well-thought-out even for remotely located facilities. Ideally, the clinic is located on the ground floor of the building, he adds. That’s because older patients can become confused getting into an elevator, finding the correct floor, then locating the office.
Under ideal circumstances, the office is accessible to public transportation as well as cars, says Leibrock. Some older patients rely on buses or trains to get to their appointments. And, of course, parking should be as close to the entrance of the office as possible. Leibrock recommends installing a resting place – a bench — every hundred feet or so in the parking lot and throughout the corridors of the medical facility, if necessary.
“It’s important to have a good passenger loading zone,” because many older people are dropped off at the office’s entrance by a caregiver, adds Leibrock. Curb ramps should be installed. Better yet, curbs should be taken out altogether, if possible.
As the patient approaches the building, he or she should be able to visually identify the entrance, so there’s no question about how to get into the building, Leibrock points out. Outside signage should be tactile, so people with low vision can find their way. She also recommends putting some kind of audible cue – such as wind chimes – near the signs, so older patients with low vision can easily find them.
Valet parking could be a tremendous service, depending on the practice and/or location, and how used to the concept people are, says Leibrock. “A lot of hospitals do it; there’s no reason why a larger ambulatory setting shouldn’t consider it.”
Hirth agrees with Leibrock that if the medical office can eliminate stairs to the entrance, it should do so. But when stairs are unavoidable, they should be well-lit at night, and they should be clearly marked.
At those clinics unable to provide close-by parking, Marshfield provides a shuttle/transportation service to the front door, either with a bus or a golf cart, says Colburn. Medical office buildings should also have wide entrance doors, so patients with wheelchairs or motorized carts can get through, he adds. Marshfield provides a variety of wheelchairs at its doors.
Glare can prove to be problematic for older people entering an office building, says Leibrock. “Contrast glare” is the “dazzle effect” one gets when going from a bright, sunlight-drenched area to a darker one, or vice versa. To address the problem, designers should consider building a transition entryway, which is a little bit darker than the outside, but brighter than the interior. Office planners should install window treatments that reduce the “dazzle,” she adds. Sheers or blinds can soften the light inside the office.
Having had an electronic medical record system for a number of years, Marshfield Clinic has the capability of automating many of its processes, but it is doing so judiciously. “We’ve discussed automated check-in, similar to e-check-in at the airport,” says Colburn. “But we’re reluctant to do it. I feel that the human touch, that interaction at the front desk, is important to the patient visit.”
Regarding the reception desk, medical office managers must balance the need to protect the staff from potentially infectious diseases (by installing some kind of physical barrier), with the desire to provide a welcome, open interface between the patient and staff, says Colburn. That’s an issue not only for elderly patients, of course, but for all patients, he adds. Regardless of how that dilemma is handled, the reception desk must be clearly visible to the patient – and that may be more of an issue for elderly patients.
“Upon entering, you should be able to see very clearly where reception is,” says Leibrock. Offices should avoid putting a big plant in the middle of the waiting room, which might obstruct the patient’s view of the front desk. What’s more, the office should try to provide some kind of privacy for patients checking in, so others don’t overhear the patient’s name, reason for visit, etc. Leibrock also recommends that, if possible, the office have a separate outside exit, so patients don’t have to traipse through the waiting area after a physical exam. “These are ways to maintain more security, dignity and control for the patient,” she says.
Windows in the reception area help the older person maintain his or her orientation, says Leibrock. They also give the patient access to daylight and nature, and that can facilitate healing. Windows also capture light without running up energy costs.
The waiting room
The doctor’s office should have a simple layout, advises Hirth. “There shouldn’t be a lot of angles and corners,” on which people can bump themselves and get hurt. And the flow of traffic – from check-in to the vital signs area to the exam room – should be simple
Personal cues provide more effective “landmarks” than impersonal ones, says Leibrock. So, for example, if the office hangs a framed antique dress on the wall, the older patient is more likely to remember instructions to “Turn left at the antique dress” than “Turn left at the plant.” Leibrock on occasion has recommended that medical offices put a fountain near the reception area, so the patient can hear – and then locate – it from anywhere in the building. However, the tradeoff is an increase in ambient noise levels.
Chairs, flooring and lighting are three important considerations for the waiting area of tomorrow’s medical office, according to experts. “We like chairs with arms, because they’re easier to get out of,” says Hirth. “We don’t want them too low or too high, though.” Non-slip flooring is important. “If someone has to put a lot of effort into getting out of the chair, we don’t want it to slide.”
The waiting room should have chairs of all varieties and sizes, to accommodate patients of different heights and with different disease states, such as orthopedic problems, says Leibrock. Wide chairs to accommodate obese people are essential today.
Chairs should have plenty of clearance under the seat, that is, no crosspieces, adds Leibrock. That’s because older people tend to extend their feet under their chair before pushing off. The chair’s arms should be well forward, so the older person can lean forward when getting out of the chair. Heavier chairs are preferred. “You want a chair that won’t tip over if you lean on one arm,” she says.
Sofas are OK, but they shouldn’t be so plush that the person’s closed fist sinks more than an inch or two when he or she is pushing off the sofa to get out, says Leibrock. Soft sofas may also “bottom out,” and patients with bony prominences on their spine can suffer injury. For a person with reduced circulation, just a few hours of sitting in such a sofa in the waiting room can lead to pressure ulcers, she points out.
Drinking fountains should be of a variety of heights, Leibrock continues. Many older people have difficulty stooping over low fountains.
The ease or difficulty with which the older patient can navigate the office not only has to do with its layout, but with lighting, flooring and handrail supports.
“In our exam corridors today, some physicians are walking 300 feet from their office to the exam room,” says Colburn. Patients must make treks just as long. Marshfield is evaluating how to make that a more manageable distance. “Ninety or 100 feet from reception to the farthest room in the corridor may be a requirement,” he says.
Older people need five times the quantity of light as that needed by their younger counterparts, says Leibrock. “But it has to be without glare, so you don’t simply want to take it up five times.” Rather, offices should give patients some method of controlling their own lighting, maybe with task lighting or individual access to a ceiling light, which the patient can control.
Another issue for older people is “veiling reflection,” that is, the glare on reading materials, floors and counters caused by lighting, window and door placement, says Leibrock. “It’s a big issue for older people, who may have thickened lenses, cataracts or muscles that don’t react quickly to changes in light.”
Bright lights, shiny floors and older patients are a bad combination. “Medical offices love shiny floors, because they look clean,” says Leibrock. “But older people see that as water on the floor, and that’s the scariest thing.” Ways to minimize it include: installing multiple sources of lower-level lighting in halls; avoiding placing windows or doors at the end of long hallways; and installing carpeting instead of shiny flooring material. Today’s carpets have antimicrobial properties, she says.
Slip-resistance is a big issue for the physician’s office. Rubber floors score high on slip resistance, but they look institutional, and they absorb greases and creams that might spill on them, says Leibrock. Linoleum may be a bit outdated, but it’s pretty slip-resistant. Ceramic mosaic with a lot of joints provides a pretty good defense against falls too. For wood floors, Leibrock recommends applying a polyurethane/oil finish to minimize slipping.
“And of course, there’s carpeting,” she adds. Research shows that older people increase their gait speed and stepping confidence on carpeting. What’s more, carpeting absorbs ambient noise – another issue for the elderly. Offices installing carpeting would be well-advised to do a few things, according to Leibrock:
- Specify a carpet with a moisture barrier, so that if an older person has an accident, urine won’t penetrate through to the subfloor.
- Seal a concrete subfloor with an acrylic polymer, so that if urine does get through, the subfloor won’t absorb it and create an odor.
- Consider laying carpeting directly on the subfloor, that is, without a pad. Such floors are easier for wheelchair users to negotiate than those with thick padding.
Handrails are an essential part of the medical office serving the elderly. Leibrock advises that handrail extensions be installed at the top and bottom of stairs, to give patients time to regain their balance should they feel unsteady. Returns on handrails must be such that patients’ clothes don’t catch on them. In addition, the inside edge of the handrail shouldn’t extend more than an inch and a half from the wall. That’s because older people tend to lean against handrails with the flats of their arms; if the rail is too far from the wall, the patient’s arm can get caught or, worse, broken.
Vertical handrails should be installed in bathrooms, so men standing at the toilet won’t lose their balance. Such handrails are also suggested for scales, should the patient feel slightly off balance. Speaking of bathrooms, Hirth suggests grab bars, plenty of non-glare lighting, and an emergency call system.
The exam room
The most important consideration for the exam room is space. Simply put, there should be plenty of it. “You need to have a room that’s big enough to accommodate a wheelchair,” says Amy Annis, Hospital Associates, an Anaheim, Calif.-based distributor. “And you need one or two side chairs.”
It’s no secret many exam rooms are too small, she continues. And they’re getting more crowded all the time. “With EMR systems, you have to consider the fact that there might be a computer on a stand in the room; that’s another 18-to-24-inch footprint.”
Without adequate space in the exam room, the nurse or doctor might be forced to take assistive devices, such as scooters or walkers, out of the room during the exam, notes Jon Wells, director of marketing, medical products, Midmark Corp., Versailles, Ohio. “The patient feels isolated. Even though they had no intention of moving, they’re uncomfortable.”
Adds Colburn, “Elderly patients typically [come to the medical office] with another person, a companion.” Many patients need assistive devices as well. So larger, more comfortable exam rooms are necessary.
Marshfield is evaluating putting sofas in its exam rooms. A sofa offers more flexibility than chairs, says Colburn. “They can accommodate a lot of body types; children can stand next to their moms; and if the patient isn’t feeling well, they can lie down on the sofa and close their eyes until the care provider enters the room.”
Exam room doors should be such that they maximize the patient’s privacy, says Colburn. Magazine racks, mirrors and a place to put one’s glasses during the exam are desirable features. And whenever possible, Marshfield Clinic tries to mount medical equipment on the walls of its exam rooms, in order to maximize the flexibility of the rooms.
Lighting is an issue in the exam room, as everywhere else in the office, adds Colburn. “We’re very concerned about the color temperature of the lamps, so the physician has an accurate rendering of the coloration of the patient’s skin.” Lighting should be flexible; if the doctor needs more light, he or she should be able to bring it up; and if he or she needs less, it should be dimmable. “And because of conservation, we’re looking at room occupancy sensors or day sensors,” he adds.
Many facilities in the Northeast are replacing their fixed-height exam tables with handicapped-accessible tables, which can be lowered and raised as needed, notes K. C. Meleski, sales rep, Claflin Equipment Co., Warwick, R.I.
Says Leibrock, “You want an exam table that will lower to the 17- or 19-inch height of wheelchair users, allowing you to transfer them to the table, and then raise them up for the convenience of the physician.”
But even box tables can be made safer for the elderly, notes Wells. Footsteps can be rubberized and surrounded with bright edges, so they are more visible. In fact, all edges in the exam room should have bright edges, he says. “The room is as safe as possible, so people don’t unintentionally hit something and get thrown off balance, which could lead to a fall.”
Stirrups should have straps, so that elderly people with some degree of paralysis or whose limbs are not sensitive to touch can be assured their feet are secure, says Leibrock.
“Dignity is a real big issue when you get older,” says Leibrock. Medical offices can do many things to preserve the older patient’s privacy. Installing an accessible changing curtain is one way to do so. Hooks for clothing should be installed at different heights – for ambulatory patients as well as those in wheelchairs. And a mirror should always be part of the exam room furniture. Patients don’t want to walk out of the exam room with hair disheveled or clothing not in place, she points out.
Meleski has noted a trend away from balance beam scales to digital scales. The digital scales allow for quicker weight-taking, he says. In addition, their platforms are lower to the ground, and they don’t move. “The balance beam scales are up six inches, and they can be wobbly,” he says. “One complaint is that elderly patients have a tough time getting onto them.”
Some outpatient facilities, such as dialysis or infusion centers, are purchasing recliners with breakaway arms, so patients can be easily transferred from a wheelchair into the recliner and vice versa, Meleski says. Many facilities are ordering side bolsters for their recliners, to effectively shrink the size of the seat.
“They tell me that when an elderly woman sits in these recliners, she can be engulfed by them, because they’re so big.”
Outpatient surgery centers are purchasing stretcher chairs as a way of limiting patient transfers, adds Meleski. Such chairs can accommodate the patient pre-op, during surgery, and post-op.
Doctor’s primary concerns are for the safety and well-being of their patients. But revenues are a close third, and failing to modify the office for elderly patients can adversely affect those revenues. “The office has to figure out ways – without making patients uncomfortable, and while keeping the user experience optimal – to get them through the system,” says Wells. And by following some of the simple solutions mentioned above, they can do just that.