Capital constraints, CON scrutiny, and the ambulatory shift are colliding with rapid value-based care adoption. Boards now expect real estate to advance clinical outcomes, operational throughput, and financial performance—measured in HEDIS/STARs, first-contact resolution, and risk-adjusted ROI.

How should our health system balance ambulatory expansion with acute care investment while maximizing capital efficiency? Bremner Healthcare Real Estate—healthcare-exclusive since 1989 and validated by acquisition by Duke Realty—builds population health footprints and clinically integrated hubs through strategic portfolio optimization, aligning location, capital structure, and care models to reduce leakage and PMPM. We act as healthcare real estate strategists embedded in operations and capital planning, not brokers of square feet.

Healthcare real estate strategy is now inseparable from value-based performance. Boards are asking how location, capital structure, and care models translate directly into HEDIS improvement, leakage reduction, and PMPM savings. Bremner’s healthcare-exclusive focus since 1989, institutional validation via acquisition by Duke Realty, and track record of $3.2B+ on-campus and off-campus developments and national health system partnerships demonstrate a proven method for execution. The sections that follow connect population health, clinical integration, finance levers, and compliance into a single operating playbook your finance committee can act on.

Value-Based Facility Alignment

Value-based facility alignment is defined as the disciplined pairing of care sites and operating models to the outcomes and access targets embedded in risk-bearing contracts. That means capital planning that starts with panels, attribution, and quality metrics—and then flows into location, clinical adjacencies, and standardized ambulatory workflows. In practice, we use care pathways to engineer room counts, team pods, and procedure bays, so providers deliver higher-value care with fewer handoffs and lower variability.

When capital was deployed around legacy volumes and not outcomes, systems saw rising costs and leakage; when we redirect capex to risk-adjusted ROI and standardize workflows, the result is higher visit capacity and measurable improvement in HEDIS and STARs. Our fiduciary lens ensures every dollar is mapped to a contractible return, not just a ribbon cutting. As a healthcare-exclusive firm since 1989, Bremner brings decades of clinical-operational design to align facilities with the incentives shaping your P&L. Explore our approach at bremnerrealestate.com and let’s anchor sites to savings, not just square feet. Schedule a strategic portfolio assessment.

Population Health Footprint

Population health succeeds when access meets need, not maps. We pinpoint high-need zip codes using claims, SDOH indices, and avoidable ED data, then seed clinics where attribution and unmet demand intersect. Travel time is the single largest predictor of no-shows, so reducing minutes to care directly boosts preventive visits and chronic care adherence. By designing for payer mix, panel density, and service scope, we reduce out-of-network leakage and improve PMPM performance.

A subtle truth: when panels churn and avoidable ED escalates, a targeted duo of access clinics co-located with SDOH partners can reverse trajectory—referrals stay in-system and risk contracts see stabilized utilization. We embed community partners on-campus for food, transportation, and behavioral support, converting social risk into clinical throughput. Our national partnerships allow us to replicate this footprint playbook rapidly, with governance and speed validated by our acquisition by Duke Realty—an institutional confirmation of delivery discipline. Request a confidential market analysis.

Clinical Integration Hubs

Clinically integrated hubs align primary care, specialty clinics, diagnostics, and low-acuity procedures to reduce friction, raise first-contact resolution, and keep patients in-network. We design team rooms for co-management, shared worklists, and quick e-consults, supported by data interoperability that pulls care gaps into the point of service. Low-acuity procedure space adjacent to primary care enables on-the-spot access, converting leakage into captured revenue and better patient experience.

Shared governance matters as much as layout. We structure hub councils that blend physician leadership, operations, and real estate, hard-wiring stewardship into everyday decisions. In our $100M+ campus developments, these hubs become the connective tissue between ambulatory and post-acute, with throughput, parking, and wayfinding engineered to eliminate lost time. For systems expanding regionally, hubs offer a scalable chassis to standardize workflows and outcomes while maintaining local relevance. A clinical integration hub is a co-located ambulatory setting that unifies primary care, specialties, diagnostics, and procedures to improve first-contact resolution. Discuss your system’s specific real estate challenges.

Health System Finance Levers

Capital is scarce, but value is abundant when structures align incentives. We deploy asset-light strategies, JVs, and off-balance-sheet financing that protect ratings while freeing growth capital. Long-term rent can be tethered to savings realized under risk-bearing contracts, creating a virtuous alignment between facility performance and P&L. The aim is balance sheet efficiency without operational compromise.

Bremner’s strict governance—sharpened through our integration with Duke Realty—ensures institutional-grade controls, FMV rigor, and transparent waterfall economics. We negotiate JV terms that preserve clinical control, expand access, and de-risk delivery, while aligning recapitalization options to milestone achievements. The difference is not just financing, but fiduciary stewardship that blends real estate returns with clinical outcomes. Schedule a strategic portfolio assessment.

Investment Timing Discipline

Timing is strategy. We phase developments to risk milestones—attribution targets, contract start dates, and provider onboarding—so capital hits when value can be realized. Optioning parcels protects the right to expand while minimizing carry, and modular shells provide flexibility for future service lines without cost-prohibitive rework. This combination reduces downside while maintaining speed to market.

A phased MOB-ASC sequence can be the difference between trapped capital and productive, metrics-backed growth. Where demand signals are strong but immature, we deploy swing space and demountable partitions to right-size operations today and scale tomorrow. That discipline preserves ROI when market conditions shift and new modalities emerge. Request a confidential market analysis.

Certificate of Need Strategy

Winning CON requires evidence, sequencing, and site control. We pair filings with development phasing—staking early claims where need is demonstrable and following with ancillary components as volumes validate. Competitive alternatives are anticipated with robust demand modeling, access gap analysis, and stakeholder alignment that clarifies why your proposal is the lowest-cost, highest-quality option.

Site control, traffic engineering, and licensure-readiness narratives strengthen approvals by showing the state a complete, executable plan. Our track record reflects how governance, documentation, and community benefit messaging turn support into signatures. When the problem is a crowded CON lane, the solution is data-rich differentiation, and the outcome is timely approval with minimal conditions. Discuss your system’s specific real estate challenges.

Data-Driven Market Selection

Claims, referral, and SDOH analytics reveal not just where patients live, but where they decide; our heatmaps merge travel-time isochrones with leakage nodes to identify high-yield sites. We present board-ready NPV and scenario models that translate market insights into capital allocation choices under uncertainty. This ensures investments are justified in both mission and margin terms.

Here’s the strategic question: where should advanced analytics direct the next clinic lease to minimize travel time, maximize attributed lives, and reduce total cost of care per episode? By simulating provider mix, operating hours, and service scope, we quantify the sensitivity of returns to real operational levers. The result is a shortlist of sites that outperform alternatives across growth, margin, and equity-of-access dimensions. Schedule a strategic portfolio assessment.

Ambulatory Portfolio Optimization

Most ambulatory portfolios carry legacy inefficiencies—redundant leases, misaligned suite sizes, and underutilized satellites. We consolidate locations to strengthen panels, renegotiate economics, and redesign suites for flexible use, lifting provider productivity without expanding footprint. Lease consolidation alone can unlock 10–15% occupancy savings when executed with a definitive provider deployment plan.

Sale-leasebacks can release trapped capital for care expansion while preserving operational control through thoughtful lease terms and capital expenditure protocols. The goal is not to shed assets indiscriminately, but to rebalance the portfolio against strategy, risk, and access. As a healthcare-exclusive partner since 1989, we know the clinical textures that make these moves stick. Request a confidential market analysis.

Digital-Enabled Care Settings

Digital care is a facility strategy, not a software add-on. We design telehealth-forward clinics with virtual rooming, remote monitoring bays, and command center adjacencies that convert no-show risk into same-day virtual throughput. Exam rooms flex to video consults; team pods support asynchronous care plans; and power/data pathways anticipate technology refresh cycles.

Cap rates increasingly reflect technology obsolescence risk, so we specify infrastructure that extends useful life and mitigates valuation drag. A fact worth noting: ambulatory sites designed for hybrid visits maintain higher panel continuity and lower variable costs per encounter than analog clinics. By integrating digital-first operations with in-person excellence, systems protect margin and access simultaneously. Discuss your system’s specific real estate challenges.

$3.2B+ Campus Developments

Regional strategy often requires scale. We deliver $100M+ campuses that phase MOBs, ASCs, imaging, and post-acute services to align growth with contract timing and workforce availability. Throughput, structured parking, and wayfinding are engineered to reduce dwell times and raise capacity without additional staffing—a design choice that compounds savings over decades.

These anchor campuses serve as distribution hubs for surrounding clinics, telehealth, and home-based care, consolidating specialty access while preserving community proximity. Our national partnerships compress timelines and standardize playbooks, so each incremental campus learns from the last and performs from day one. Schedule a strategic portfolio assessment.

National System Partnerships

Speed and consistency win in competitive markets. Our national system partnerships enable portfolio-level financing, national vendor leverage, and replicable design standards that reduce cycle time from site control to day one operations. By deploying the same hub-and-spoke chassis across markets, health systems lower unit costs and maintain clinical quality at scale.

Two additional truths bear mentioning: centralized procurement shrinks build cost variance, and standardized room templates cut training time for traveling teams. With repeatable structures, the capital committee sees line of sight from strategy to savings, not one-off projects. Our acquisition by Duke Realty affirmed this model—governed, scalable, and dependable across geographies. Request a confidential market analysis.

Duke Realty Validation

Institutional confidence matters. Bremner’s acquisition by Duke Realty validates our market leadership, governance standards, and delivery discipline. For boards and finance committees, that means an execution partner with enterprise-grade controls, from contracting to change orders to delivery risk management. It also means depth of bench—development, compliance, and operations working as one.

We apply that rigor to both single clinics and $100M+ campuses, bringing consistent outcomes: on-time openings, budget adherence, and facilities that perform clinically from day one. In a capital-constrained environment, credibility with lenders, rating agencies, and community stakeholders is a tangible asset. Discuss your system’s specific real estate challenges.

Bremner Healthcare-Exclusive Since 1989

Exclusivity in healthcare real estate isn’t a tagline for us; it is the foundation of how we underwrite, design, and deliver. Since 1989, we’ve navigated cycles, reimbursement shifts, and clinical innovation curves, giving us muscle memory for what endures. Our fiduciary stewardship record reflects that history—transparent economics, FMV rigor, and decisions that put patient value and provider effectiveness first.

Embedded clinician-operator collaboration is our signature; it’s how buildings become care accelerators instead of cost centers. We translate provider workflows and quality metrics into square footage, adjacencies, and equipment plans that scale across markets. The result is durable value aligned to the mission. Schedule a strategic portfolio assessment.

Risk Management and Compliance

Compliance is strategy’s guardrail. We build Stark and Anti-Kickback diligence into every lease structure, maintain third-party FMV opinions, and conduct lease audits for consistency with provider-based billing. Licensure-readiness and life-safety are planned upfront, not retrofit, to protect opening dates and payer credentialing.

A facility that opens on time but requires post-occupancy code remediation erodes ROI; instead, we front-load regulatory design and documentation so surveyors find a compliant, ready site. Our institutional governance—strengthened through Duke Realty—reduces execution risk and creates audit-ready trails that withstand scrutiny. Request a confidential market analysis.

Implementation Roadmap

Execution creates value. We begin with a 90-day diagnostic to map leakage, access gaps, and financial levers, prioritizing moves with the highest clinical and financial yield. From there, a 12–36 month phasing plan sequences clinics, hubs, and campuses to contract milestones, workforce availability, and licensure timelines.

How to operationalize the plan:
1) Complete a 90-day diagnostic to baseline access, leakage, and rent-to-revenue.
2) Approve a phased portfolio plan tied to risk-contract milestones and workforce onboarding.
3) Stand up a governance council and KPI dashboard covering access, capture, quality, and capital performance.
4) Execute phased builds and lease actions with quarterly course-corrections based on live data.

A live KPI dashboard tracks access, leakage, provider productivity, and rent-to-revenue, with cadence reviews that allow course correction as data emerges. When issues surface—like unexpected no-show pockets—we adjust hours, transit links, or telehealth capacity and measure results, keeping strategy tethered to outcomes. Schedule a strategic portfolio assessment.

FAQs

For off-balance-sheet developments, we typically combine a credit-aligned master lease, FMV rents, and capital expenditure protocols, preserving operational control while optimizing ratings impact; JV options can add alignment when physician syndication or ASC participation is strategic. Ambulatory shift and leakage capture often deliver 15–25% lower per-episode costs and 3–7 percentage points improvement in in-network capture when hubs and referral pathways are designed in tandem.

Sale-leasebacks can be EBITDA-neutral to accretive when proceeds retire higher-cost debt and leases are structured with maintenance reserves and renewal optionality; rating agencies focus on predictability of cash flows and governance quality. Multi-market CON filings should be phased to demonstrate demand sequentially, leveraging early wins, shared data rooms, and site control to strengthen later cases.

Post-occupancy, boards should track access (third-next-available), panel growth, capture rate, no-shows, rent-to-revenue, quality metrics tied to contracts, and facility utilization per room per day, ensuring sites remain aligned to value. Discuss your system’s specific real estate challenges.

Partner with Healthcare Real Estate Strategists

If your organization is aligning capital to risk-bearing contracts, expanding population health access, or contemplating $100M+ campus scale, a purpose-built real estate strategy is a controllable lever for outcomes and margin. Bremner’s healthcare-only focus since 1989, national system partnerships, and governance validated by Duke Realty equip boards with a replicable, data-driven path from concept to clinical performance.

Contact Bremner for healthcare-focused real estate strategy consultation.