Shifting care from hospitals to ambulatory centers

The familiar scent of antiseptic and the hushed anxiety of a hospital stay are slowly giving way to a more convenient and cost-effective alternative for many patients in western North Dakota: ambulatory surgery centers (ASCs). Just recently, McKenzie Health in western North Dakota has seen a shift in procedures moving from hospitals to these outpatient facilities, a trend driven by factors such as cost, convenience, patient preference, technological advancements and payer reimbursement structures. This transition, while promising greater accessibility and affordability, presents unique challenges for rural communities like Grafton, where the delicate balance of healthcare infrastructure is crucial for maintaining essential services. The shift towards ASCs isn’t just about changing where procedures are performed; it’s about reshaping the very fabric of healthcare delivery in our state, and how we ensure that every neighbor has access to quality care, close to home.

What's Happening: The Shift to Ambulatory Care

The movement of procedures from hospitals to ambulatory surgery centers isn't a sudden phenomenon, but rather a gradual evolution within the healthcare industry. According to Pete Edis, CEO at McKenzie Health, minor orthopedic, general surgical, ENT, urology, pain management, gynecological and other lower-acuity procedures are increasingly being performed in outpatient settings. This shift is fueled by several factors: advancements in technology allowing for minimally invasive techniques and improved anesthesia protocols; a growing patient preference for convenience and faster recovery times; and payer reimbursement structures that incentivize outpatient care. A study by the National Institutes of Health confirms that ASC growth is more prominent in higher-resourced counties with historically underserved communities. Joe Wendt, senior vice president of operations at Essentia Health, notes that more complex or severe elective procedures, particularly total knee, hip, and shoulder replacements, are also moving to ASCs.

The transition isn’t limited to surgeries; it encompasses a broader range of services. Wendt highlights the expansion of nonsurgical services such as infusion therapy, imaging, wound care, rehabilitation, dialysis, remote monitoring and even some home-based care. This comprehensive approach emphasizes a patient-centered model where care extends beyond the operating room and into the patient’s home or community. Sanford Health, for example, has entered into a joint venture for an ambulatory surgery center in Grand Forks and is converting inpatient areas into outpatient facilities at the Roger Maris Cancer Center in Fargo. Essentia Health's partnership with Brightside Surgical in Bismarck aims to retain physicians, patients, and procedures while expanding access and preserving hospital capacity—a strategy increasingly favored by healthcare executives. More than 60% of health system executives identify ASCs as a leading joint-venture opportunity.

However, the question isn’t simply “Can this procedure be performed on an outpatient basis?” but rather, “What setting gives this particular patient the best opportunity for a safe and successful outcome?” This patient-centric approach is crucial, especially in rural areas where individual circumstances often dictate the best course of action. For example, Edis explains that McKenzie Health continues to hospitalize many total joint patients for one to three days, and some subsequently utilize swing-bed services for rehabilitation, particularly when they have become deconditioned prior to their procedure. This is often due to patient circumstances rather than the procedure itself; many patients live far from Watford City, including rural ranchers, and lack access to home healthcare or physical therapy.

The Impact on Rural Communities

The shift towards ASCs presents a complex reality for rural North Dakota communities. While the potential for cost savings and increased convenience is appealing, the financial implications for hospitals are significant. Hospitals face higher overhead costs associated with 24/7 emergency, inpatient, and diagnostic services. Mike Delfs, CEO and President of Jamestown (ND) Regional Medical Center, emphasizes that if too much procedure volume is diverted from local hospitals, it can jeopardize the sustainability of essential services. This is particularly concerning in rural areas where the patient pool is smaller, and the revenue from individual procedures directly supports the broader healthcare infrastructure.

Delfs highlights the unique challenges faced by rural critical access hospitals, which often provide extended care beyond surgery. Keeping a total joint replacement patient an extra day or two allows therapists to improve mobility and ensure a safe recovery before returning home, avoiding frequent long-distance travel for outpatient surgery. The concern isn't about preventing outpatient procedures; it’s about ensuring the entire healthcare system remains viable and capable of providing emergency care, inpatient capabilities, home care, and other essential services. “Rural healthcare policy needs to consider the sustainability of the entire local healthcare system, not simply the cost of an individual procedure,” Delfs stated.

The reality is that many rural patients live 50 miles or more from a hospital, often on gravel roads that are difficult to navigate year-round. These communities lack the same level of support services available in larger urban areas, making the transition to outpatient care even more challenging. The need for a holistic approach that considers the entire healthcare ecosystem is paramount to ensuring that rural residents continue to receive the care they need, when they need it.

Supporting Rural Healthcare

Local healthcare providers are committed to supporting rural communities and ensuring that patients have access to the care they need. They are working with government agencies and community organizations to develop strategies that support rural healthcare infrastructure and ensure that patients have access to the care they need, regardless of where they live. Community leaders emphasize the importance of maintaining a strong, interconnected healthcare system that serves the entire community.

The Future of Healthcare in North Dakota

Looking ahead, healthcare providers anticipate further shifts in care delivery. Delfs predicts an increase in outpatient surgeries and a greater integration of diagnostics, infusion services, rehabilitation, behavioral health, and chronic disease management into outpatient or home-based settings. He foresees a future where hospitals may look different, with fewer traditional inpatient days but more outpatient specialty care and diagnostics.

Sanford Health plans to expand home-based services like “Hospital at Home,” remote monitoring, and virtual care. Strategic real estate planning will be crucial to meet patient demand and maintain quality standards. Essentia Health aims to focus hospital campuses on emergency, intensive, complex surgical, and high-acuity care, repurposing excess space and partnering with outpatient providers. This approach allows for continued investment in rural communities and helps close the gap between urban and rural access to expert care.

Wendt believes hospitals will increasingly focus campuses on emergency, intensive, complex surgical and high-acuity care while repurposing excess space and partnering with outpatient providers. “This is particularly exciting for a system like Essentia, with its service area mainly comprising rural communities. With smart rural investment, we can continue closing the gap between urban and rural access to expert care,” he said.

Maya’s Perspective

Watching this shift unfold, I can’t help but think about the families I know – folks who rely on the stability of our local hospitals not just for surgery, but for the peace of mind that comes with knowing emergency care is available nearby. The move to ASCs promises benefits, certainly, but it also raises questions. How do we ensure that the financial pressures on our rural hospitals don’t compromise their ability to provide those essential services? How do we support the ranchers and farmers who live miles from the nearest clinic and depend on those extended hospital stays for rehab after a procedure? These aren’t just economic questions; they’re about preserving the fabric of our communities, about ensuring that every child has access to the care they need to thrive. The American dream isn’t just about individual success; it's about building strong, resilient communities where families can flourish. We need to be vigilant, asking hard questions and demanding solutions that prioritize both efficiency and the well-being of our neighbors.

Resources for North Dakotans

For more information about healthcare services in North Dakota, residents can visit the following resources:

• North Dakota Department of Health
• McKenzie Health
• Essentia Health
• Sanford Health
• Jamestown (ND) Regional Medical Center
• State of North Dakota
• City of Grafton
• North Dakota Chamber of Commerce
• North Dakota State University
• Rural Health Information Hub

The healthcare landscape in Grafton and across rural North Dakota is constantly evolving, and it’s crucial for residents to stay informed and engaged in the conversation about the future of healthcare in our communities.