Establishing a Continence Center

• Business Plan
• Personnel and Equipment Requirements
• Marketing
• Physical Plant
• Conclusion
• Suggested Reading

A continence center represents a center of excellence concept. A specific commitment to making a unique entity is required to fulfill this goal. This commitment should represent a high degree of motivation to provide unique and progressive care for patients afflicted with voiding dysfunction. The center of excellence concept implies a global approach to these patients, not only interventional, but also educational and supportive. A high degree of frustration is often encountered in patients with chronic urinary dysfunction and this sentiment must be considered when managing these patients.

The approach of such a center should include a multi-specialty component. Urologic care often coexists with a urogynecologic role in a complementary relationship. For centers with a large ambulatory female population, gynecologic support for chronic hormonal supplementation, surveillance for uterine and breast disease, and care of other chronic postmenopausal problems such as osteoporosis, are positive additions. Gastroenterology and neurology services further complement the comprehensive care pattern.

Although it is difficult to create an exact template for the establishment of a continence center, some basic components should be considered to provide this type of service. This article addresses four interrelated issues that are necessary in the formulation of a continence center: 1) business plan; 2) personnel and capital equipment requirements; 3) marketing; and 4) physical plant.

Business Plan

The business plan represents the operative financial document for the continence center. A well-conceived plan can be vital in acquiring initial outside investment and in attracting institutional support. The following information should be included in the plan:

• Goal statement/mission overview (inclusive of an executive summary)
• Review of pertinent and national and regional demographics
• Structured financial projection
• Analysis of competing entities
• Marketing concepts
• Pertinent appendices (ie, analysis of required physical plant needs and local market alternatives)

In determining the thrust of the plan, a clear concept of the financial relationships required for initiating the center must be formulated. The center may exist as an independent site, as an outgrowth of a moderate to large single or multi-specialty group, or as an institutional department (a major factor in regional female health initiatives). The type of partnership should be expressly agreed upon from the outset so as to effectively partition investment and profit/loss determinations. A partnership may be sole, limited, or general.

The goal/mission statement section provides the background information that is crucial to understanding the societal requirements and medical necessities for the center. Reference to governmental data[1,2] regarding the care of incontinence are appropriate for emphasis.

The demographic section can be based on already established incidence and prevalence data available from Medicare statistics, as well as from population projections derived from Gallup polls and the American Foundation for Urologic Disease (AFUD) estimates commissioned by the American Urological Association. These data can be stratified on loco-regional statistics pertinent to the referral population. The estimates of population data are vital for creating a cogent financial argument in the next section of the business plan.

The detailed financial projections include initial equipment, personnel, and growth estimates expressed as cost/benefit (loss) analysis. This analysis should be cautiously optimistic (4­8% annum volume increase), and should be expressed over a period of 3 to 5 years for purposes of profit projections. Initial financial outlays can range from $10,000­$150,000. Expenditures will be mandated by available equipment, spatial needs, and projected personnel support.

The competitive analysis should include other urologic and urogynecologic centers as well as geriatric and freestanding commercial (mainly biofeedback/urodynamic consultative centers) locales. In some cases, partnership can be considered to avoid market saturation.

Personnel and Equipment Requirements

Support staff services are crucial to successful functioning of this initiative. The center requires a small but competent group of professional individuals who work synergistically with the physician contingent. Ideally a nurse clinician experienced in continent care forms the backbone of the center. This individual represents continuity of care, formulates much of the daily regime, and has the integrity and ability to work independently directing the center's day-to-day operations. Additional personnel is dictated by volume and need, but typically include a receptionist, billing expert, and a technician or licensed specialist for urodynamic/biofeedback studies.

Equipment needs can be tailored to local circumstances, using creative lease purchase agreements or other equipment-sharing possibilities. If possible, urodynamic capabilities should be provided by a unit capable of multiple channel pressure transduction, with electromyographic recording capabilities. For continence initiatives with multiple channel locales or with commitments to other health care sites, the urodyamic unit should be relatively mobile. Post-processing capabilities are ideal for this type of unit. Newer systems also combine simultaneous capabilities for pelvic floor physiotherapy (biofeedback and electrical stimulation) with advanced urodynamic recording. This type of system is especially attractive to smaller centers as a cost-saving combination for needed capital equipment. Other diagnostic requirements include instrumentation for bladder and transvaginal ultrasonography and cystoscopy.

As advancements in urethral injectable technology continue, in-office ability to perform transurethral injection therapy is a necessary component of the ambulatory continence center. Improved transurethral delivery systems have substantially decreased the time for injection and increased patient acceptance of this method of therapy.

Marketing

Marketing efforts require a detailed understanding of the care delivery area, as well as prudent financial planning to ensure reasonable capital expenditure. Marketing can potentially be an extremely expensive venture if not carefully budgeted. Marketing tools should be viewed as positioning the center to attract customers, and as a public service and educational endeavor. Marketing venues include print, audio, and video media. Particularly effective venues include special interest publications and seminars and conventions targeted to seniors and women.

A brochure describing the center and its capabilities is a very useful tool for targeted mailings as well as for presentation to referring physicians and other health care groups. The brochure should stress advancements in diagnostics and therapeutics.

Physical Plant

Ideally, a continence center occupies a specific locale that allows for the creation of a specific entity (ie, single specialty group, multi-specialty clinic, hospital, or tertiary referral center). The spatial requirements for such a center vary, according to the referral population size and the characteristics of the entity. Absolute size may range from 1,000­3,000 square feet or greater to accommodate a dedicated area to perform urodynamics and other diagnostics, in conjunction with a second procedural area for outpatient therapies and secondary diagnostics (cystoscopy, ultrasound). Other areas for treatment, education, and support services such as billing and scheduling are required according to volume of care delivered.

For larger groups, a virtual concept can be pursued, with mobile diagnostics and therapeutics that can be placed in multiple locales depending on patient care requirements, physician and support staff availability, and equipment needs. The virtual concept is currently being used in our locale. This paradigm allows rapid allotment of personnel and equipment to areas of need conveyed by patient volume requirements. Multiple sites are used which provide convenient and rapid care to patients dispersed over a wide geographic area.

Conclusion

A continence center provides multiple benefits to the individual practitioner and to group and institutional entities. Personally, patient satisfaction and positive response to this type of initiative has been an extremely gratifying experience. The patient approbation and appreciation for the effort and care involved has been an outstanding success. From the societal viewpoint, center-driven educational and support groups have had positive effects for significant groups of patients otherwise without an option for medical care for a socially disabling disease. Many institutions have similarly experienced substantial improvement in patient ratings when centers have been added to overall health initiatives. Finally, under prevailing reimbursement patterns, voiding dysfunction and continence care remain feasible clinical options. However, a high level of commitment is necessary for success.

Suggested Reading

• Clinical Practice Guidelines Update: Urinary Incontinence for Adults. Rockville, MD: Agency for Health Care Policy and Research, US Dept of Health and Human Services; 1992-1996.
• Federal Register/HCFA reimbursement changes. National Institutes for Health/National Institute for Aging admission and morbidity data.

Dr. Dmochowski is medical director, North Texas Center for Urinary Control, Fort Worth, TX.