As healthcare’s ambulatory boom accelerates, hospitals are preparing to care for more medically complex patients.
Outpatient care volumes are expected to rise by 18% over the next decade, while inpatient care will see a more modest growth rate of 5%, according to a June forecasting report from Sg2. Inpatient acuity, however, is expected to rise and many health systems are already seeing this shift play out.
“We are beginning to see changes in our case mix index in the inpatient world, implying that we are treating sicker patients in the process,” Todd Smith, MD, chief physician executive at Sacramento, Calif.-based Sutter Health, said in a recent interview for the “Becker’s Clinical Leadership Podcast.”
At Northwell Health, ambulatory care now accounts for 53% of its business, Jill Kalman, MD, chief medical officer of the New Hyde Park, N.Y.-based system, told Becker’s. The system has been ahead of the curve in growing its outpatient footprint over the past few years. At the same time, it has not seen a dip in inpatient volumes — a reflection, she said, that more patients are receiving care in the most appropriate setting, resulting in a higher proportion of medically complex patients in the hospital.
Adapting care models to meet rising acuity
To support this shift, clinical leaders are actively redesigning care delivery models to enable inpatient teams to focus more of their time on direct patient care in the safest, most efficient manner possible.
“We have a unique opportunity to redesign the care model entirely, and respond to the increasing complexity of our patients, while simultaneously improving the healing environment and our nurses’ well-being,” said Amber Price, DNP, MSN, RN, senior vice president and chief nursing officer at Norfolk, Va.-based Sentara Health.
Jason Brown, MD, executive director and chief medical officer of clinical services at Phoenix-based Banner Health, shares a similar view.
“Hospitals must fundamentally reimagine their role as centers for the most critically ill patients while developing new capabilities to support this shift,” he said.
This involves smart utilization of technology, such as virtual nursing and AI to simplify daily administrative pain points.
“AI and technology allow us to optimize safety, work more efficiently, and detect patterns of redundant work that we aim to eliminate, in order to give time back to our nurses,” Dr. Price said.
“This will also allow us to reduce the administrative and charting burden, and build a scheduling model that accounts for historical unit acuity, while allowing team members to choose how and when they want to work,” she added. “The goal is to develop a model that makes nursing a sustainable career and gives our patients the healing environment they deserve, minimizing interruptions and optimizing high-touch nursing care.”
On the technology front, leaders anticipate predictive analytics and digital tools will play a growing role in enabling care teams to practice at the top of their license. Sutter, for instance, is working to embed predictive modeling to support clinicians with early identification of patients whose condition may be deteriorating. The system is also leaning into virtual observation, or virtual sitting, to monitor patients at risk of falls or other safety events, which frees up time for staff at the bedside to provide higher-level care delivery, Dr. Smith said.
As workforce shortages persist, staff efficiency and adaptability will become increasingly critical to ensure hospitals can provide high quality care to more patients who require intensive care and monitoring. Leaders are employing a variety of strategies to maximize these capabilities among their clinical teams, including cross-training staff and embracing team-based care models.
At Ohio County Healthcare — a small, rural system based in Hartford, Ky. — nurses work across medical surgical and high-acuity units.
“We rotate them in and out to make sure that everybody is able to take care of high-acuity patients because our staffing is minimal,” said Athena Minor, DNP, MSN, RN, the system’s chief nursing and clinical officer. “You don’t have a lot of people that you can call upon, so they have to be knowledgeable. We have to make sure that they’re skilled and knowledgeable when it comes to taking care of patients. I think more people are going to have to start doing that.”
More services moving outpatient means those facilities will require greater staffing manpower and resources, placing a tighter squeeze on the clinical workforce. As such, leaders say team-based care models will be a defining feature of inpatient care in the coming years.
“These shifts will exacerbate the existing, industrywide workforce shortage,” said Daniel Roth, MD, executive vice president and chief clinical and community division operations officer at Livonia, Mich.-based Trinity Health. “It will require all of us to transform care models by embracing team-based care supported and enabled by technology. We will need to have more collaboration and people working together maximizing each other’s capabilities around the needs of the patient.”
Dr. Kalman pointed to the nation’s aging population and growing prevalence of chronic conditions as factors driving higher acuity in the inpatient space. As such, leaders are constantly reassessing how inpatient care teams are structured to meet evolving needs. For instance, as more surgical patients present with comorbidities such as diabetes and heart failure, the system is exploring ways to leverage hospitalists to better co-manage these conditions, allowing surgeons to focus more fully on procedural care.
“Having hospitalists managing the coronary disease and the diabetes is incredibly useful and allows the surgeons to do the work they intend to do,” she said “We have to look at all of this quite comprehensively and not just rely on the same models.”
Some systems are beginning to embed team-based models that involve greater reliance on advanced practice providers in acute care settings.
“Anticipating a higher case mix index, we have already established a structured APP onboarding and training program specifically tailored to our acute care needs that ensures that our APPs will be well prepared to care for an increasingly complex inpatient population,” Dr. Price of Sentara said.
The health system recently created the one-year program to build confidence among APPs transitioning to practice and improve retention. Akin to a physician residency, the program includes weekly clinical education sessions, mentor meetings and competency evaluations.
What comes through in leaders’ remarks is that no single strategy or change will adequately prepare hospitals to meet the demands of caring for more critically ill patients. Instead, hospitals must take a multifaceted approach that layers care model innovation and digital tools to achieve the highest levels of safety and efficiency.
The case for a balanced approach
Beyond care model redesigns, the ambulatory boom will require hospitals to build highly effective and reliable care coordination infrastructure so patients — especially those with complex conditions — transition seamlessly between sites of care without delays or confusion.
“Health systems that view ambulatory growth as an opportunity to redesign their entire care ecosystem will thrive,” Dr. Brown of Banner Health said, pointing to the system’s joint ventures with Atlas Healthcare Partners — an ambulatory surgery center management group — and Select Medical, a post-acute rehabilitation provider. “These partnerships are strategic investments in care continuity and our patients’ long-term health,” he added.
By and large, health system leaders recognize that ambulatory expansion is critical to deliver on the industry’s broader aims to make healthcare more accessible and affordable. However, they also emphasize that this shift requires a steady and balanced approach by both providers and regulators to avoid unintended consequences.
“What concerns me is that there is such a push and such a shift to keep patients out of the hospital that I fear there are going to be patients who need an inpatient stay who aren’t going to receive it because they won’t be allowed to do so,” said Dr. Minor of Ohio County Healthcare. “We already see that sometimes with pre-authorizations.”
Her concern echoes broader conversations unfolding across the industry following a recent CMS proposal to eliminate the inpatient‑only list. The policy, which would start by removing 285 musculoskeletal procedures in 2026, means hospitals would no longer be guaranteed inpatient reimbursement for those procedures because Medicare would consider them eligible to be performed in outpatient settings. In response, leaders have called for safeguards to ensure appropriate site-of-care decisions and for the implementation of robust quality monitoring in outpatient settings to match the standards seen in inpatient care.
“When you look at the diagnosis and say, ‘this patient doesn’t need to stay in the hospital,’ you’re not looking at the whole patient,” Dr. Minor said. “A patient may have the same diagnosis as another patient who can go home, but they may need more time for healing. I’m afraid that type of judgement is going to be overlooked and we’ll start to see patients go home before they should go home.”
As more investments and resources flow toward ambulatory services, health system leaders emphasize that hospitals will always play a vital role in caring for their communities.
“Hospitals still play a critical role in managing complex and acute cases,” Dr. Roth of Trinity said.
“We must ensure hospitals remain adequately staffed to deliver safe, high-acuity care, even as resources and workforce expands in outpatient environments.”
