The impact of the Affordable Care Act on emergency services has resulted in the consolidation and closing of a significant number of hospital-based emergency departments creating mergers, acquisitions and network affiliations in recent years. Coupled with this trend is the addition of new emergency department (ED) consumers through the expanding insurance exchanges, the shrinking primary care provider pool and decompression of under-performing hospital based EDs. The need for 24-hour access to urgent and emergent care with more affordable choices in more convenient packaging has opened the door for the development of the freestanding emergency department (FSED). This market response has resulted in the reemergence of the FSED as an expanding option to hospital-based EDs. Initially the FSED was a concept that was launched in the 70s as a model that was designed to serve underdeveloped rural markets. Today, however, the drivers include faster service, better access and the option of providing the consumer with a choice of care in an upscale patient experience. These are just a few of the things that have separated FSEDs from their traditional hospital-based counterparts. This shifting market has resulted in FSEDs that have experienced a 65% growth rate since 2006. Information provided by the Advisory Board Company suggests that the FSED represents about 3-5% of hospital admissions with an average length of stay between 60-90 minutes.


This trend is in large part due to improved access in fast-growing, under-served markets with service options that are more streamlined and that mirror most hospitalbased EDs with board-certified emergency trained physicians who are often employed by the sponsoring acute care hospitals. In addition, emergency trained nursing extenders are working closely with physicians and other specialized team members to complement the care delivery model. However, this accelerated growth and expansion raises questions as to their appropriate response to the new market conditions. For the consumer, there can be some confusion between the choice of options offered between a licensed FSED and the less lower acuity options offered through urgent care centers and quick stop clinics in retail and pharmaceutical settings. Considering the annual patient volume of an FSED is typically in the range of 16,000 – 20,000 visits or 35 – 40 patients/day compared to a hospital-based ED, the demographic and market share is more concentrated and focused which drives the facility considerations and strategies to ensure the project performs to business plan.


To respond to this market, several hybrid models have emerged including the healthplex or health park which offer a broader base of service offerings. The typical stand-alone ED focuses primarily on urgent and emergency services, with limited lab and imaging capabilities. The typical FSED operates 24 hours a day, 7 days a week with an average of 8-12 beds. On the other end of the spectrum is the health park model, which could include upwards of 15 beds with expanded observation bed options, outpatient imaging services, occupational medicine, physical therapy, rehab services and outpatient surgery services, to name a few potential program enhancements. The opportunity to co-locate the FSED in a health park or similar outpatient center with these, and other complementary services, coupled with specialized retail is an option that should be carefully examined and the benefits carefully weighed. This approach could provide a potentially more synergistic solution to the patient experience, including one-stop shopping with proximity to primary care and specialty clinics. This proximity of provider to care center would improve the opportunity for building a larger and more robust referral network. In addition, freestanding emergency departments can potentially provide an effective strategy for a provider to service their market area appropriately with the option to expand upward into a full-service acute care hospital as community needs mature. This approach has been proven effective when the facilities and services are master planned around a solid strategic and operational business plan.

Freestanding Emergency Department in Spokane, Washington

Freestanding Emergency Department in Spokane, Washington

There are currently approximately 400-500 FSEDs located in about 16 states. The regulations vary widely by state, as authorities having jurisdiction (AHJs) recon-cile license and certification requirements for this deliv-ery care model, further complicating the implementation process. For example, many AHJs view the FSED as an outpatient service under the existing main hospital license; others don’t allow ambulance transfers under any circumstances. It is important to understand these requirements and how they relate to the owner’s opera-tional model. A facility that is strictly an outpatient serv-ice, and not under separate license, may be appropriate for an owner who is interested in developing an outpa-tient health park; but not necessarily a practical means to provide a platform for the development of a future hospital campus. In some cases, this has been an out-growth of state reviews where the Certificate of Need (CON) programs govern the review and approval process.
The 2014 Design Guidelines for Hospitals and Outpatient Facilities has been expanded to include this building type but reference many of the traditional hospital ED functional attributes in the performance guidelines. Program expansion will likely be required to justify community acceptance and longer term need. In addition, several other considerations would include the following:


Facility Considerations:

• Ancillary Testing
• Heliport Transport Site
• Clinical Care Services
• Medical Emergencies/Transportation
• Hours of Operation
• Registrar Work Area Within Treatment Zone
• Bedside Registration and Discharge
• Urgent/Non Urgent Minor Care
• Workflow/Crossover Traffic
• After Hours Separate Entrance
• Dedicated Walk In/Ambulance Pick Up
• Visibility of Caregivers
• Pharmacy Fume Hood
• Instrument Cleaning/Sterilization
• Gyn/Psych/Prisoners/Isolation/Bariatric/Pediatrics/Geriatrics
• Monitored Rooms
• Family/Portable Equipment/Universal Room

• Offstage/Onstage Zone
• Paramedics Backboards/Charting/Cleaning Equipment
• Location/Size Provide for Future Expansion

Functional/Operational Programmatic Considerations:

• CDU/Observation Decompression Area
• Five Functional Zones
• Patient Intake
• Treatment
• Clinical Support
• Administrative Support
• Building Support
• Efficient Staffing Model
• EMTALA/Governance
• Contracted Services
• Specialization and Cross Training
• Licensing and Certification
• Telemedicine
• Technology: Call-Ahead Scheduling/Self Triage
• Electronic Health Records
• Strategies to Grow Services
• Convenient Parking/Entry Point
• Heli-Pad Transport


Business/Financial Considerations:

• Business Plan/ROI/ Salary/Incentive-Based Income/RVUs
– Development Lease or Build?
– Facility Fee Licensing
• Ownership Structure (Hospital/Healthcare System vs. Private Physician/Physician Group and/or Investor Owned)

• Insurance Contracting
• Independent FSED vs. Outpatient ED. All Levels of Care Stabilization/Observation


Marketing /Promotional Considerations:

• Tailoring the Message
• Faster/Convenient/Less Expensive
• Aging Population Demographic
• Proximity to Physician Offices
• Competition/Target Demographic
• Population Trends
• Cost Escalation/Affordable Lower Cost Options
• Referrals/Improve Access to Medical Services

Each of these unique challenges are pursued with the ultimate goal of optimizing patient care, while fulfilling the triple aim of healthcare reform – better health, bet-ter care and cost containment.
Sources: The Advisory Board Company

Tom Testerman bw 5-5-15 a _3Tom Testerman is the Director of Healthcare Planning at HFR Design. He can be contacted at 

This article was originally published in HFR Perspectives on Health Healthforward Report Newsletter Vol. 7 #4

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