Community Health & Wellness

Freestanding ERs proliferate on the peninsula

Posted on December 23rd, 2025 By: Conor Wilson

Six months ago, board-certified physicians employed by health care nonprofit MultiCare started delivering care to patients at a satellite emergency room along Highway 303 in Bremerton. The 10,500-square-foot building is some 35 miles north of the company’s closest hospital in Tacoma.

MultiCare has been among Washington’s biggest backers of so-called “freestanding” emergency departments, opening seven facilities that offer emergency care in buildings detached from a hospital campus. Most are located in communities like Bremerton, that have limited access to care or an overcrowded hospital.

Construction of these facilities is part of a national surge in freestanding ERs that swept the county for a decade but only recently come to the peninsula. Proponents argue they expand access to quick, convenient medical care close to a patient’s home, while siphoning those with lower acuity conditions away from busy hospital emergency rooms.

Those claims are being tested in Kitsap, where three freestanding ERs opened this year. They hope to expand access to care and alleviate pressure at the notoriously busy St. Michael Medical Center emergency room. The Silverdale hospital was Kitsap County’s only emergency department for years. At times, it has faced chronic overcrowding.

MultiCare in East Bremerton on Thursday, Nov. 20, 2025.

In addition to MultiCare’s “Neighborhood ER” in East Bremerton, Virginia Mason Franciscan Health opened two hybrid ER-urgent care clinics in Kitsap County. The company, which owns St. Michael and St. Anthony in Gig Harbor, said earlier this year that the Silverdale hospital continued to see over 200 patients a day, demonstrating an obvious need for more access points.

“We are committed to listening to the community and responding to the greatest needs of our patients,” VMFH interim-president Chad Melton said in February, following the opening of the Bremerton Hybrid ER along Kitsap Way. “[This project] is a great example of this work in action.”

Growth in freestanding ERs

The concept of the freestanding emergency room was pioneered in Texas. The state has more than 330 freestanding ERs, according to a 2024 study published by researchers at Texas A&M University. They handle about a quarter of all emergency room visits. All three of the freestanding ERs in Kitsap were built in collaboration with Texas-based companies.

The model has since spread across the country. Growth has come in tandem with a decline in access to primary care physicians. As fewer people across the country have an established primary care provider, they tend to seek care in the emergency department for sudden or pressing medical issues.

Dr. Nathan Schlicher of Gig Harbor, an emergency room physician and past president of the Washington State Medical Association, said the growth of freestanding ERs is “an acknowledgement that same-day access to your primary care doctor is no longer possible for most people.” The average wait time for a primary-care appointment is now 26 days, he said.

Freestanding ERs are subject to few federal regulations, creating a fragmented environment where laws differ by state. Washington, for example, requires all freestanding ERs work under the license of an existing hospital. That’s not a requirement in Texas, where independent ERs have proliferated.

Some have questioned the effectiveness of freestanding ERs. Critics worry that these facilities drive patients with lower acuity conditions to seek unnecessary emergency care, almost always the most expensive way to get treatment. Patients can also easily mistake ERs as more budget-friendly urgent cares, they say.

Combining freestanding ERs and urgent cares

VMFH has attempted to mitigate concerns about patient costs at its two freestanding ERs by offering urgent care in the same building. Physicians and other practitioners triage patients depending on their conditions and then bill accordingly. Low acuity patients are sent to the urgent care side, saving them from higher costs associated with unnecessary emergency room visits.

“The overall goal of our hybrid Emergency and Urgent care locations is to eliminate the need for patients to guess which level of care is most appropriate and ensure they only pay for the level of care they need,” Melton, the VMFH president, said through a spokesperson. “This saves patients time, money and helps reduce stress.”

St. Michael Medical Center president Chad Melton glances up at the crowd lining the second floor as he leads a round of applause for the staff of the hospital during a ceremony for the completion of the new patient tower at St. Michael Medical Center on Tuesday, Dec. 9, 2025.

Intuitive Health, a Texas-based company created in 2008, claims to have pioneered the hybrid ER-urgent care model. It partnered with VMFH to open facilities in Bremerton and Port Orchard this year that are described as the first of their kind in Washington. Melton argues they have already demonstrated widespread benefit.

VMFH sees about 84 patients per day at its Bremerton hybrid ER and another 60 in Port Orchard. About two to three per day go from those facilities to St. Michael. On occasion, patients proceed to local children’s hospitals or St. Anthony to get care closer to home. Patient wait times at St. Michael and stays in the hospital ER have dropped since those facilities opened, Melton said. Patient experience score and those leaving without being seen have also improved.

“We are also seeing higher acuity patients at SMMC, which shows us more patients are being seen at the right level of care,” he said.

Moving into the Kitsap market

For MultiCare, the opening of its freestanding ER represents an expansion into Kitsap County and a more direct relationship with its emergency medical system. The company founded in Tacoma had maintained a small footprint on the peninsula. The 12-room freestanding ER is its first emergency project.

Before it opened in June, Virginia Mason Franciscan Health ran the only emergency room in Kitsap County. After Naval Hospital Bremerton converted its emergency department into an urgent care in 2014, VMFH became the county’s sole provider of emergency care.

“MultiCare does have a presence there, on the Kitsap Peninsula with other clinics and medical facilities, so it was not out of the realm that we would look to add more services in that area,” said Scott Thompson, a MultiCare spokesperson. “When we see a need that’s not being met we want to see what we can do to remedy that situation.”

Dr. Heather Justice, medical director of MultiCare’s Bremerton ER and board member with the Western Washington Emergency Care Physicians, said St. Michael was obviously busy. That made Bremerton an ideal location for MultiCare to open its sixth “neighborhood” emergency department.

The facility has seen about 11,000 patients, about 60 per day, since it opened on June 9, she said. It has the capacity to serve a higher volume. Many of MultiCare’s satellite ERs see twice that number each day. About 2 to 3% of those patients are transferred to either St. Michael or another hospital.

MultiCare first three freestanding ERs in Parkland, Bonney Lake and South Hill, opened between 2019 and 2020, were designed to relieve pressure at Good Samaritan Hospital, a MultiCare facility in Puyallup with a busy ER. Additional ERs followed in Federal Way, Lacey, Union Gap and Lynwood.

“MultiCare’s desire is to meet the needs of the patient in the community in which they live,” Justice said. “A lot of times there have not been emergency departments or hospitals in these communities. By bringing in emergency services it allows people to seek care closer to home.”

Certificate of need isn’t needed

Another appeal of these facilities is that they are much easier to permit. They bypass controversial state certificate of need laws, which require construction of medical facilities, like hospitals, get prior approval from the Washington state Department of Health.

Freestanding ERs do not require this authorization, Justice said. State law only requires freestanding ERs be linked to and within a specific distance of a hospital, she said, although was unable to cite a specific state statute. A spokesperson for the Washington Department of Health did return a request for comment seeking specific state regulations of freestanding ERs.

Justice, who has helped launch four of MultiCare’s freestanding ERs, said the Bremerton facility has been warmly received and that the company looks forward to expanding its footprint in Kitsap County.

“There’s always some hiccups going into a new county and dealing with a new EMS system,” she said. “We’ve learned a lot, and I think we’ve come a long way in a matter of six months.”

How emergency transports work with multiple ER facilities

Kitsap County EMS providers also continue working to better incorporate the freestanding ERs into their transport rotations, said Jim Gillard, chief of the Poulsbo Fire Department and chair of the Kitsap County EMS and Trauma Care Council.

EMS and hospital officials have developed criteria together about who can go to a freestanding facility. That policy treats VMFH and MultiCare’s ERs the same, he said, while prioritizing lifesaving care above all else.

“The salient point is that anyone who needs to get to imminent care is going to go to the right hospital that can care for them as quickly as possible,” he said.

Opening the three freestanding facilities has led to some improvement in wait times for first responders transferring people to St. Michael Medical Center staff, Gillard said. Ambulances have often spent long periods of time outside the hospital, waiting for the staff to admit the people they transport.

Average wait times for EMS transport — the amount of time it takes emergency responders to transfer a patient to hospital staff — have been under 15 minutes for a majority of the year, according to data provided by Gillard. However, there are still instances where EMS are dealing with long wait times and are held up, unavailable for additional calls.

A better measure of the situation is 90th percentile response times, which is the amount of time it takes to turn over 90% of patients to hospital staff. That has fluctuated from just under 30 minutes to above 45 so far this year, according to data from Gillard. That is above the goal of 20 minutes.

“We’re getting a slow but steady improvement in wait times, but they’re not nearly where we want them to be,” Gillard said. “The free standing EDs when we start utilizing them more appropriately — or are able to better utilize them — we’ll see more of an improvement.”

Who goes where

Generally patients taken to a freestanding ER are at low-risk of needing hospital admission to surgery or an intensive care unit. That helps avoid having to move a patient multiple times. If a patient does need to be transferred to the hospital, that is most often handled by Olympic Ambulance.

Joey Rodrigues, executive director of Olympic Ambulance, said if the patient’s situation is time-sensitive — if they suffered a heart attack or a stroke, for instance — they would go to the nearest available hospital capable of treating them. In non-emergency situations, when the patient is being admitted to the hospital a stable condition, where they end up becomes more nuanced. Some patients may end up going to Tacoma General, a hospital owned by MultiCare. It depends on a range of factors, including the physician’s orders, bed availability and patient’s preference.

“In full transparency, if the patient is stable, MultiCare is going to admit patients to MultiCare facilities most often and [VMFH] is going to admit patients into the [VMFH] hospital system whenever possible,” Rodrigues said. “But they’re not going to do that at the expense of the patient.”

Rodrigues points out even before MultiCare freestanding ER opened, the system still funneled Kitsap patients to hospitals in other counties. Often, he said, that is done either to distribute patient volumes or because hospitals in Tacoma have higher levels of sub-specialty care not available at St. Michael.

Back in service faster

Overall, Rodrigues said the introduction of the freestanding ER had contributed to a reduction in how long their ambulances are waiting at St Michael to drop off a patient. That, he says, allows ambulances to be back in service faster. Creating processes and standards for how EMS would use the new freestanding facilities was also collaborative, not profit-driven, he added.

“It’s been a huge benefit to the system,” he said. “It certainly has never felt competitive. It felt very community-driven and everyone worked together to build it.”

And even if data showed no visible dip in wait times at St. Michael, Rodrigues argues the frequent use of the freestanding ERs shows just how many people in the community had previously been forgoing care.

“If you don’t get the data that tells you that it’s really helped decompress the ER, then what you need to walk away with is we just created that much more access,” he said. “Think about how many more people weren’t accessing care before.”