Roger R. Dmochowski, MD

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.

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

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.

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 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.

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.

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.

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.

Articles

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.

Roger R. Dmochowski, MD

Articles

Establishing a Continence Center