Pro-Bono Orthopedic Hospital, Design Phase Question

[mbt1961]

I'm an architect currently designing a pro-bono orthopedic hospital for cats/dogs. We are budgeting 15M Total Project Cost (maximum), and are trying to estimate projected case load to design the facility. Our mission is to provide surgery / therapy for animals whose owners cannot afford treatment, on a referral basis only, from private practices, for pets who otherwise would have no option other than euthanasia.

How may cases per month should we expect from an average practice? How far might a potential client travel to receive a service of this type?

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[CalliopeDVM]

I'm an architect currently designing a pro-bono orthopedic hospital for cats/dogs. We are budgeting 15M Total Project Cost (maximum), and are trying to estimate projected case load to design the facility. Our mission is to provide surgery / therapy for animals whose owners cannot afford treatment, on a referral basis only, from private practices, for pets who otherwise would have no option other than euthanasia.

How may cases per month should we expect from an average practice? How far might a potential client travel to receive a service of this type?

How far people might travel for the service will depend a lot on where you are.....To some people, driving an hour or more even to go grocery shopping is normal for where they live, so driving 4 hours to a referral hospital for their dog would not be a problem. To others, even driving an hour or two would be a major trip. Likewise, how many orthopedic cases a clinic might have that need a pro-bono referral option will likely depend on how many referral options are around and their costs.

 

[WhtsThFrequency]

.....I'm not sure how this model will operate.

You will see a lot of owners who could afford to perform the surgery, but with a pro-bono hospital out there of course they are going to take that option. And it doesn't seem fair to have the vet be the one deciding whether an owner does or doesn't have the ability to pay for a surgery (i.e. by potentially refusing to give a referral if they think the owner does indeed have the funds to pay and just wants to go the cheap route, and they might be wrong on that account because they don't know all the particulars of a client's finances.) Is there going to be some sort of client income limit that will allow them to qualify? Or some other qualification? How stringent of a winnowing process will there be? These things will greatly affect caseload.

 

[mbt1961]

Our belief is that the pet owner community would likely not even know that the option existed. We don't plan on having a PR budget, our concern is simply managing the case load to make the facility functional. As such, we only expect to get cases by referral, and would expect that a private practitioner had 1) triaged the case, and 2) provided a cost for surgery/rehab to the owner, and found that 3) the owner could not afford that quoted amount, and thus opted for euthanasia. It would be at that point that the practitioner would recommend our option, as a 'last resort'.

We're very confident that they type of pet owner that is unable to afford surgery/rehab is an owner likely unaware of an option like this. We're somewhat confident that the population in general is also unlikely to know of this option, and therefore unlikely to take advantage of the situation. We absolutely do not want to compete with private practice.

As an aside, we are strongly considering pairing the facility with a CVM, and have been in discussions about doing so. This would allow students to see far more orthopedic surgical cases than they would otherwise.

I'd love to hear more of your thoughts on potential caseload.

 

[DVMDream]

Our belief is that the pet owner community would likely not even know that the option existed. We don't plan on having a PR budget, our concern is simply managing the case load to make the facility functional. As such, we only expect to get cases by referral, and would expect that a private practitioner had 1) triaged the case, and 2) provided a cost for surgery/rehab to the owner, and found that 3) the owner could not afford that quoted amount, and thus opted for euthanasia. It would be at that point that the practitioner would recommend our option, as a 'last resort'.

We're very confident that they type of pet owner that is unable to afford surgery/rehab is an owner likely unaware of an option like this. We're somewhat confident that the population in general is also unlikely to know of this option, and therefore unlikely to take advantage of the situation. We absolutely do not want to compete with private practice.

As an aside, we are strongly considering pairing the facility with a CVM, and have been in discussions about doing so. This would allow students to see far more orthopedic surgical cases than they would otherwise.

I'd love to hear more of your thoughts on potential caseload.

I have three words: Word of mouth.

Should be sufficient and make sense.

 

[DVMDream]

I doubt anyone here can even give you an idea on "potential caseload" it boils down to many, many factors including: location, economics of the area, other referral centers in the area, can the owner even provide appropriate post-op care for their pet (waste of $$ if not), etc, etc.

Not only that but quite a few orthopedic issues aren't just a quick surgery/rehab and the animal is good to go. Many of the issues require long-term follow-up and continuous rehab. Not to mention that certain conditions predispose animals to have repeat issues (ex: cranial cruciate rupture). Are you going to provide free follow-up care for the rest of these animals lives? Because you need to consider that.

Honestly, I don't see this working out well. Especially due to those 3 words I stated earlier... word of mouth. Sure, at first people probably won't know about it, but with time, people will hear about it and it will become an issue of the general public knowing it and believing they are deserving of that free service for their pet. It won't stay a "secret" or out of the "media" forever.

 

[jmo1012]

I have three words: Word of mouth.

Should be sufficient and make sense.

two more: social media.

 

[Kpowell14]

Especially if a rescue group(or a couple) finds out about you! - word of mouth + social media = lots of people finding out!

I will say, joining with a CVM would be super beneficial. I know at my school, from what I have heard, Ortho rotation = standing and holding and writing up reports... I would Love to get more Ortho experience than the 2 weeks we get.

 

[jmo1012]

Especially if a rescue group(or a couple) finds out about you! - word of mouth + social media = lots of people finding out!

I will say, joining with a CVM would be super beneficial. I know at my school, from what I have heard, Ortho rotation = standing and holding and writing up reports... I would Love to get more Ortho experience than the 2 weeks we get.

the problem is that that is a super fast way to anger the veterinarians referring cases to you. i understand that this isnt supposed to take business from them because it's meant to serve clients who would otherwise do nothing or euthanize, but the politics behind anything like this are always super dicey. also, as the teachee, you will almost always be standing there, holding, and writing reports. fact of life. i don't know how non-surgery specialists learn to do ortho cases, but it isn't as a student or an intern (not on living, client owned animals).

 

[Minnerbelle]

As much as I would love to be a naysayer on this one, I think this may possibly be workable under the right circumstances.

So Tufts has this program now where they have a primary care clinic where the clients essentially have to be on good stamps to qualify, and they have to show proof. That mostly eliminates the people taking advantage situation. Students get great surgical experience with pyos, cystotomies, spays/neuters, mass removals, dentals, enterotomies, etc... that a non boarded surgeon can do. If there is a surgeon that is available that will volunteer their time, some ortho procedures get done (and students get to do a majority of the surgery), or failing that, students get to amputate or do FHOs as a salvage procedure. I don't know who qualifies, but doesn't Davis have a similar program?

So I don't see how this couldn't be done as an ortho only situation attached to a vet school. As long as the clients are charged enough to cover material fees and low overhead (esp if parts of the teaching hospital can be used), it could happen.

If you want to get more fancy and get ortho clients that aren't that poor but can't afford the $3000 surgery, perhaps you can have a tax return verification where you can perform the surgery for people below a certain income bracket, but make it so that the pre-anesthetic workup and follow up rads have to be done at the rDVM and stipulate no other services. Or whatever, and make it referral only for those not on food stamps or something.

 

[mbt1961]

Thanks for all the comments. We've felt for a while now that the hurdle is qualifying prospective clients.

Regardless how we face this reality, what caseload might we expect - in other words, for an average practice (let's consider on a per practitioner basis), how many prospective cases might we see if we offered pro-bono surgery/rehab per year?

We assume that:
The surgery/rehab would extend the life of the animal five years minimum (i.e. the animal is not at the end of it's life)
The owner has been quoted a cost by a private practitioner, and has opted for euthanasia due to lack of funds

 

[cowgirla]

Of all the clients I've had decline surgery for ortho problems, none have elected euthanasia. The vast majority of these clients don't think that fluffy is painful just because he limps, so why would they euthanize?... As long as he's still eating/wagging his tail, they are okay watching him gimp along with blown crucuates, patellas out of place, bad hips, bone tumors, etc. would these people go for surgery if it was free? I honestly don't know- especially because it's still a huge output of time on their part.

The ones who do care but have limited funds try for plan B- the less ideal but done in house surgical option, support bandages, drugs, crate rest... Those are the ones who would go for the free surgery, and maybe it's just my area, but I have very few of these clients- most just go for the recommended surgery right away. or do nothing because "it's just a dog".

Now if you are offering IVDD and other back surgeries as well you will more than likely get lots of people wanting in. If Fluffy can't walk at all it must really be painful- but limping apparently doesn't mean pain.

Overall I think it's a great idea. But not everyone who can't afford surgery is going to go somewhere because it's free- it's just as much a client education issue as it is a financial. If everything is free, how are operating costs covered?

 

[mbt1961]

Operating costs for the facility will be carried by my client, for whom my firm is designing (and will manage the building of) the facility - our early estimate is $200K/month. He will be contributing to (and raising funding for) the construction cost. I should add that our plan is to man the facility in part with students from 2-year vet tech programs as part of their required training, and provide housing for them as part of our campus (which would also have indoor-outdoor rehab facilities and an adoption center (we are considering referrals from shelters as well, for animals very likely to be placed by adoption)).

To me (and I'm assuming here, but an educated assumption as I worked for several clinics during college) the obvious patient is an accident victim - car strike, or other trauma. Younger animal, immediate need, surgery or euthanasia option in many cases. Again, how many cases would fall into this category? I can recall several during my tenure of 12 months at a practice with two veterinarians which ended in euthanasia due to cost.

We've discussed IVDD/spinal with the CVM with which we have a relationship. My client is considering (as an aside to our facility) funding a fellowship in this area, which seems to be underserved from a research standpoint.

 

[katryn]

Personally, I see very few to no euthanasia due to cost ortho cases, but probably 2-5 per year of do nothing or do the less ideal (think splinting instead of surgery) due to cost cases.

 

[CalliopeDVM]

Orthopedic-only cases almost never need euthanasia as an alternative to surgery. Most will heal, in some way, without surgical intervention....yes, they will need pain meds and supplements to help with mobility, but that's usually manageable for the owners because the cost is budgeted over the long term, rather than them having to find the money or credit in one lump sum. The exceptions would include spinal fractures, or pelvic fractures that narrow the pelvic canal too much. Possibly seriously displaced femoral fractures. A few weeks ago a 6 month old puppy was hit by a car and had a comminuted tibial fracture, along with some ugly wounds to the back feet. No money for a surgical referral, so he's being managed with a splint and bandage changes. I've told the owner that it may heal crooked or he may have growth abnormalities in that leg, but it will heal. He's doing great right now on multi-modal analgesia.

 

[jmo1012]

Operating costs for the facility will be carried by my client, for whom my firm is designing (and will manage the building of) the facility - our early estimate is $200K/month. He will be contributing to (and raising funding for) the construction cost. I should add that our plan is to man the facility in part with students from 2-year vet tech programs as part of their required training, and provide housing for them as part of our campus (which would also have indoor-outdoor rehab facilities and an adoption center (we are considering referrals from shelters as well, for animals very likely to be placed by adoption)).

To me (and I'm assuming here, but an educated assumption as I worked for several clinics during college) the obvious patient is an accident victim - car strike, or other trauma. Younger animal, immediate need, surgery or euthanasia option in many cases. Again, how many cases would fall into this category? I can recall several during my tenure of 12 months at a practice with two veterinarians which ended in euthanasia due to cost.

We've discussed IVDD/spinal with the CVM with which we have a relationship. My client is considering (as an aside to our facility) funding a fellowship in this area, which seems to be underserved from a research standpoint.

if you are offering to trauma patients, are you also going to be equipped to handle their non-orthopedic trauma needs? because i feel like although fractures and luxations secondary to trauma are common, these are also pets that may have other problems secondary to the trauma and even if they seem outwardly healthy, a standard trauma minimum database should be applied before going to surgery (chest rads, abdominal rads, FAST scan, bloodwork, urinalysis, superficial wound care, etc). that right there is probably $800-1000 in diagnostics. does every case need this? maybe not, but if you are pairing with a teaching facility (dvm or tech or otherwise), you should do things the "right" way so that students get that experience too. it will be way more valuable to a student to learn and understand the value of trauma care than fracture management, as a lot more trauma patients will be seen (depending on the clinic) than just fractures if i had to guess (a vast majority of my fracture cases have been secondary to trauma rather than something more benign like jumping off the bed as a tiny dog)

 

[Minnerbelle]

I can only think of one patient in the last year that was ortho surgery (aside from amputation/FHO/bum legging it ) or euthanize. That was a dog with both forelimbs fractured. I don't think the pet ended up euthanized. It got surgery in the end.

Now if you can do hemilaminectomies emergently, I maybe saw 3 patients in the past year that was euthanized due to paraplegia due to IVDD based on no money for sx.

 

[DVMDream]

So this just went from a pro-bono orthopedic surgery hospital to a pro-bono orthopedic surgery hospital with long-term follow up, full rehabilitation services AND an adoption center.... I think you need to focus on one thing at a time. Not only that, I just honestly don't see this working. What are your requirements? Is this for only local people? Can I send a patient from across the country for free surgery? Where would this be located? Am I to not suggest a lower cost procedure such as amputation that the client might be able to afford? If a client can afford a lower cost procedure do they not qualify for this service? Why shouldn't they or why should they?

What is your proposed location? Number of cases will be based upon location. Random midwest town and you probably are going to be yawning a lot during the day. Busy city and you may be a bit more busy, depends on how many clinicians refer to you.

Also you really need to consider how the veterinary community in the area will perceive this. Are you going to be taking away procedures from local vets? Sure you say it is for clients that "can't afford the procedure and will euthanize" but rarely does an orthopedic issue get to that point. So then what are your requirements? Could that vet have kept that client and provided a different option for them? And are you taking away any potential income that vet could have by taking on all follow-up care as well? Is that sustainable for the veterinary community around you and for your clinic? Will you be able to even get cases referred to you from the local vets?

You mention trauma as a potential cause for orthopedic cases, but often times the ortho issues in those patients are the last things that are dealt with or worried about. If a client isn't going to be able to afford the cost to repair their dog's fractured femur, they are unlikely to be able to afford to stabilize their pet prior to even getting to the point of surgery. It isn't the orthopedic injuries that might end the dog in euthanasia but instead the other injuries sustained with the traumatic incident.

I think there is a lot more that needs to go into this "planning" before you even begin to worry about a possible case load. The biggest one being how will the veterinary community respond to this idea and will this even work out? The second being what are the qualification of getting one of these free surgeries and can we realistically provide all follow up care for the patient without making the referring clinician feel as though we are taking away some of their job?

 

[jmo1012]

$200k seems like a low budget if you are in a reasonably populated area. orthopedic equipment and implants are expensive. does that also cover cost of keeping the facilities open? realistically, i'd expect each case to cost $2.5-5k. and like i said above, if you are going to involve students (and really even if you dont), cases need to be managed with high quality care. doing rads before and after and at follow ups. doing pre-anesthetic bloodwork. having good anesthetic drugs and pain management available. having good anesthesia equipment. this shouldn't become some low cost cut corners clinic if you expect to be respected in the community of local practitioners (and i think its already questionable that you will perceived as anything other than stealing business for a majority of cases honestly).

 

[mbt1961]

So this just went from a pro-bono orthopedic surgery hospital to a pro-bono orthopedic surgery hospital with long-term follow up, full rehabilitation services AND an adoption center.... I think you need to focus on one thing at a time. Not only that, I just honestly don't see this working. What are your requirements? Is this for only local people? Can I send a patient from across the country for free surgery? Where would this be located? Am I to not suggest a lower cost procedure such as amputation that the client might be able to afford? If a client can afford a lower cost procedure do they not qualify for this service? Why shouldn't they or why should they?

What is your proposed location? Number of cases will be based upon location. Random midwest town and you probably are going to be yawning a lot during the day. Busy city and you may be a bit more busy, depends on how many clinicians refer to you.

Also you really need to consider how the veterinary community in the area will perceive this. Are you going to be taking away procedures from local vets? Sure you say it is for clients that "can't afford the procedure and will euthanize" but rarely does an orthopedic issue get to that point. So then what are your requirements? Could that vet have kept that client and provided a different option for them? And are you taking away any potential income that vet could have by taking on all follow-up care as well? Is that sustainable for the veterinary community around you and for your clinic? Will you be able to even get cases referred to you from the local vets?

You mention trauma as a potential cause for orthopedic cases, but often times the ortho issues in those patients are the last things that are dealt with or worried about. If a client isn't going to be able to afford the cost to repair their dog's fractured femur, they are unlikely to be able to afford to stabilize their pet prior to even getting to the point of surgery. It isn't the orthopedic injuries that might end the dog in euthanasia but instead the other injuries sustained with the traumatic incident.

I think there is a lot more that needs to go into this "planning" before you even begin to worry about a possible case load. The biggest one being how will the veterinary community respond to this idea and will this even work out? The second being what are the qualification of getting one of these free surgeries and can we realistically provide all follow up care for the patient without making the referring clinician feel as though we are taking away some of their job?

Thanks for the comments and guidance. Programming any facility is a process of gathering answers which often illicit more questions, which then must be responded to before design begins. We're in Programming, not formal design, so we are testing a concept, not forwarding one well defined. The facility has always been envisioned (the concept) as one with post surgical care (until the patient can return to their owner), rehab services for non-surgical care (with the potential for testing orthopedic medical devices as a part of the CVMs research grant funding stream), and adoption an center. These may change as we develop a better understanding of need, and of what our partner CVM can accommodate. I'll take a shot at responding to the questions you pose above:

Our proposed location is the southeast US.
Our #1 goal is to supplement deficiencies in the for-pay veterinary private practice community - we can't survive without buy-in from private practitioners.
Our requirements - how patients are referred - are being developed based on interviews with private practitioners, and on other sources (such as your comments above, all very insightful). We are VERY early in this process.
Our initial belief is that once a case is well enough for release, all follow-up care would be done by the referring practice - this would be made clear before a case was accepted. Our belief at this point is that the owner has to demonstrate some level of commitment - cost - and that our facility is like a bridge to alleviate a catastrophic need.
While we do plan to triage and prep for surgery, the CVM would be responsible for the surgery and for non-orthopedic care. On a case by case basis, our foundation may cover part or all of the cost of that care, reimbursing the CVM, and the owner may be responsible for covering part or all of the cost of that care. HOW this is determined is something (as you might guess) that we are still working through as a business model.

 

[mbt1961]

$200k seems like a low budget if you are in a reasonably populated area. orthopedic equipment and implants are expensive. does that also cover cost of keeping the facilities open? realistically, i'd expect each case to cost $2.5-5k. and like i said above, if you are going to involve students (and really even if you dont), cases need to be managed with high quality care. doing rads before and after and at follow ups. doing pre-anesthetic bloodwork. having good anesthetic drugs and pain management available. having good anesthesia equipment. this shouldn't become some low cost cut corners clinic if you expect to be respected in the community of local practitioners (and i think its already questionable that you will perceived as anything other than stealing business for a majority of cases honestly).

Thanks for the comment, jmo. The client is interested in anything but a low-cost solution. We would rather be very discriminating in our choice of patients - limiting the number - and providing success stories for fewer animals than providing low cost high throughput solutions. In talks with the CVM, we see it (and they see it) as more of a cutting edge test bed for new techniques and new therapies, working in conjunction with medical device and pharma partners.

I note your bio lists NCSU. As an aside, I'm currently involved in the redesign of research Module B in CVM Main.

 

[jmo1012]

Thanks for the comment, jmo. The client is interested in anything but a low-cost solution. We would rather be very discriminating in our choice of patients - limiting the number - and providing success stories for fewer animals than providing low cost high throughput solutions. In talks with the CVM, we see it (and they see it) as more of a cutting edge test bed for new techniques and new therapies, working in conjunction with medical device and pharma partners.

I note your bio lists NCSU. As an aside, I'm currently involved in the redesign of research Module B in CVM Main.

i did my 4th year at NCSU, so i'm only familiar with the Terry Center and large animal/equine facilities 🙂 [I actually have no idea what module B is or where the cvm main is, though i suspect that's the non-clinical portion of the hospital?]

 

[mbt1961]

Could anyone conceive of resistance to the concept IF we chose to bring in ONLY animals from shelters? The animal would probably need to fulfill all of the following requirements:
1) have a reasonable life expectancy remaining
2) have a reasonable chance at adoption following rehab/surgery

I will add that, as we are discussing an association with a CVM, and we may wish to expand the scope to partner with medical device / pharma manufacturers to further research on specific products and methodologies, we may include a third parameter

3) have a unique medical issue which would make the animal a reasonable subject for medical device testing / pharma trials

From the perspective of private companies involved in the development of medical devices / pharma products, wouldn't they prefer to gain access to a larger population of animals for their research, and limit variables by bringing them together under one roof to study?