THE INDEPENDENT MEDICAL BUSINESS JOURNAL
Volume XXXII, No. 03
Housing as health care Addressing the needs of the homeless BY WILLIAM E. WALSH, MD, AND JON L. PRYOR, MD, MBA
very physician knows the feeling of failure despite providing the best medical care. George was my example. George was brought to HCMC’s Emergency Department (ED) with a severely broken jaw after being assaulted at a transit station, but our staff quickly discovered that he had also been drinking heavily to numb his physical pain. Because George needed his jaw reconstructed, I became George’s surgeon, and our team repaired his fractured mandible. Although patients with an isolated mandible fracture are usually discharged a day or two after the repair, this was not possible for George because he is homeless. Where do we send a postop patient experiencing homelessness? Shelters would not take him due to his medical complexity after surgery, so George needed to stay at HCMC until we found him a place to live. Catholic Charities, an amazing partner of
Elder abuse Addressing an underreported problem
Housing as health care to page 124
BY MARIT ANNE PETERSON, JD
lder abuse is a prevalent and profoundly underreported experience that affects many older adults, their families, friends, and communities. A broadly used definition for abuse describes it as any intentional or negligent act that causes a harm or a risk of harm to an older adult. Elder abuse can include many forms of maltreatment and crime, including physical and sexual abuse, emotional abuse and threats, financial exploitation and theft, and neglect or self-neglect. Although most physicians may be in a position to recognize forensic markers for physical forms of abuse, the National Center on Elder Abuse (NCEA—ncea.acl.gov) reports that 10–40 percent of abuse victims experience “polyvictimization”—more than Elder abuse to page 104
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JUNE 2018 MINNESOTA PHYSICIAN
TH 50 SESSION JUNE 2018
CONSOLIDATION IN HEALTH CARE
Volume XXXII, Number 3
COVER FEATURES Elder abuse Addressing an underreported problem
Housing as health care Addressing the needs of the homeless
By Marit Anne Peterson, JD
By William E. Walsh, MD, and Jon L. Pryor, MD, MBA
Examining cost and quality issues
Creating new ways to deliver value
AUTOIMMUNE DISEASES 34 Systemic lupus erythematosus
Thursday, November 1, 2018, 1-4 pm
Research drives hope By Erik J. Peterson, MD
James Hereford, MA Fairview Health Services
The Gallery, Downtown Minneapolis Hilton and Towers 1101 Marquette Avenue South
BACKGROUND AND FOCUS:
HEALTH CARE ARCHITECTURE HONOR ROLL
Consolidation in health care threatens the viability of the system and is escalating at an alarming pace. Patients are left with fewer choices, both in terms of which Eleven outstanding building projects 22 doctor to see and in terms of treatment options, including medications, from the By Richard Ericson doctor they do see. Costs are often increased and quality often decreases when systems become too large. Demands to comply with increasing regulations leave SPECIAL FOCUS: MEDICAL FACILITY DESIGN many medical practices in a bind. How can they maintain independence without Value stream mapping 14 the infrastructure of a large system? Focusing on the patient’s experience
By Chad Frost, BSME, BSEM
Violence in the ED
18 We will examine the root causes of health care consolidation. We will illustrate what has worked and what has not. We will explore cases where FTC regulations By Elizabeth Schulze, AIA, LEED AP BD+C are pushed to the limits and the threat to patients this poses. We will look at the Predesign in health care construction 20 larger continuum of care and how public health issues are impacted by consolA critical first step idation. We will discuss state legislative initiatives that need to be in place and what must be done to keep patient well-being at the center of health care delivery. By Jason R. Grabinger and Richard P. Engan, AIA, CID, LEED AP Planning and designing for safety
Scott M. Jensen, MD Senator, District 47, MN Legislature
Center for Diagnostic Imaging
Scott R. Ketover, MD, AGAF President and CEO, Minnesota Gastroenterology, PA
Minnesota Gastroenterology, PA
LIz Quam Executive Director, CDI Quality Institute
Mike Starnes, email@example.com
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Essentia Health Moves Forward with Multi-Million Dollar Renovation Plan Essentia Health’s board of directors has approved planning, financing, and construction for Vision Northland, a project that includes a large-scale renovation for Essentia’s downtown Duluth campus set to take place over the next four years. Essentia Health will invest about $675 million to replace buildings on its downtown Duluth campus as well as $125 million on related infrastructure and financing. The plan also includes funds from the city and state infrastructure money from the Legislature. Hospital officials say it is the largest private development in Duluth’s history and some have compared it to what Mayo Clinic did in Rochester with its Destination Medical Center. The project will build 800,000 square feet of new facilities and renovate about 114,000 square feet of existing facilities. The plan includes
building a new St. Mary’s Medical Center, clinic building, and outpatient surgery center. The overall footprint will be reduced by 240,000 square feet and condensed from spanning multiple blocks to two blocks, which Essentia says opens up space for future development. The health care system is now working to finalize schematic designs and a master construction plan. The project is expected to be complete in 2022. “While significant construction will take place, it’s important to note that this is not about new buildings,” said Herman. “It is about focusing on the practice of medicine and how we can best advance our mission to make a healthy difference in the lives of those we are privileged to serve.”
Centracare Health Expanding Telestroke/ Vascular Neurology Services CentraCare Health has received a federal grant of more than $560,000
to expand its Telestroke/Vascular Neurology Clinic services to eight new sites, organizing a collaborative network of 16 locations that will cover most of rural Minnesota. The three-year grant, awarded by the Department of Health and Human Services’ Rural Health Care Services Outreach Program, will provide telestroke outreach and navigation efforts across a 12-county area so patients suffering from a stroke or TIA (transient ischemic attack) can access specialists via telemedicine equipment and receive care locally instead of traveling to St. Cloud Hospital. The telestroke outreach and navigation services will be implemented at CentraCare Health–Monticello; Appleton Area Healthcare Services; CHI–St. Gabriel’s Health (Little Falls); Douglas County Hospital (Alexandria); Madison Healthcare Services; Renville County Hospitals and Clinics (Olivia); Rice Memorial Hospital (Willmar); and Riverwood Healthcare (Aitkin). The expansion covers Aitkin, Douglas, Kandiyohi,
Lac qui Parle, Morrison, Renville, and Wright counties, in addition to the existing network that currently serves Pope, Stearns, Swift, Todd, and Wadena counties. The expansion is expected to take about two years and add access for almost 7,000 square miles, covering an additional quarter-million people. Once completed, the network will cover more than 11,000 square miles and nearly 500,000 people will have access to the services.
Fentanyl-Involved Deaths Increasing Significantly There was a sharp increase of deaths in 2017 caused by the synthetic opioid fentanyl, according to a preliminary analysis of death records by the Minnesota Department of Health (MDH). The number of synthetic opioid-involved deaths increased by 74 percent from 2016 to 2017, according to the preliminary data. Fentanyl was a major factor in the increase—of the 172 deaths that involved synthetic
Providing (and Protecting) High Quality, Cost-Effective Patient Care The Minnesota Ambulatory Surgery Center Association (MNASCA) is a statewide, non-profit trade association OUR MISSION MNASCA is dedicated to promoting quality, value-driven outpatient surgical care. We are committed to ensuring that surgery centers continue to thrive as a distinct model for the delivery of safe, affordable and advanced surgical services to Minnesota’s health care consumers. OUR MEMBERS Our 42 certified member ASCs provide a full range of surgical services. MNASCA supports members through advocacy, outreach, communication, and supporting legislation that lowers the cost of care and increases the quality of health care outcomes. OUR MEMBERSHIP MNASCA offers a variety of membership levels, including individual/nurse membership, associate membership (for our non-ASC supporters), and full facility membership.
Join us for our Annual Conference (venue pending) Thursday, October 11 & Friday, October 12, 2018 Additional details will be posted at www.mnasca.org 4
JUNE 2018 MINNESOTA PHYSICIAN
For questions about MNASCA, our annual conference, or memberships, please contact Rachel Stuckey at email@example.com.
opioids, 156 (91 percent) had fentanyl listed as contributing to the death on the death certificate. “This dramatic increase shows that the opioid epidemic in Minnesota has also become a fentanyl public health crisis,” said Jan Malcolm, Minnesota commissioner of health. “These data confirm that Minnesotans addicted to opioids may unknowingly be exposing themselves to far greater and more deadly risks than they know.” The rise in deaths related to fentanyl is outweighing some progress happening in other areas involving opioids, such as decreases in prescription opioid and heroin deaths—the number of heroin deaths actually decreased by 29 percent from 2016 to 2017, according to the preliminary data. However, overall there was a 3 percent increase in opioid-related deaths, from 675 in 2016 to 694 in 2017, which MDH attributes to fentanyl.
Mayo Clinic Urologists Study Opioid Prescribing Patterns, Implement New Guideline A study by urologists at Mayo Clinic has identified unwarranted variation in post-surgery opioid prescribing patterns. The team has also taken steps to create a standardized approach across Mayo Clinic’s campuses in Arizona, Florida, and Minnesota. Researchers assessed postoperative opioid prescribing patterns for urologic surgeons at all Mayo Clinic’s campuses and convened a multidisciplinary task force of members from Mayo Clinic’s urology, anesthesiology, nursing, pharmacy, and health services research departments. The group obtained prescribing data for 21 common urologic procedures over a two-year period from 2015 through 2016. They then assessed the data in descriptive terms and performed statistical analysis to identify trends in prescribing patterns based on patient demographics, with a particular interest in patients with no history of chronic opioid use. “Nearly 80 percent of the patients in our study were prescribed an opioid,
SINCE 1894 tradition of caring and we identified significant variation enrichingLIFE SINCE 1894 among the surgical procedures we anbuildingCOMMUNITY feel atHOME alyzed,” said Matthew Ziegelmann, The STRENGTHEN enrichingLIFE MD, a urologist at Mayo Clinic and Transitional co-author of the paper. “Refill rates were also variable, ranging from 2 HEART ENGAGE buildingCOMMUNITY SINCE 1894buildingCOMMUNIT percent to 25 percent.” He added that tradition of CARING HEART patients more likely to receive a larger atHOME dose of opioids at dismissal included enrichingLIFE feelatCenter
younger patients, male patients, and those with a cancer diagnosis. Those more likely to request a refill were younger patients, female patients, and those with a benign diagnosis. Patients who received more opioids at discharge were also were more likely to obtain a refill, suggesting that they were not under-prescribed. The team used this data to create an evidence-based, procedure-specific, tiered guideline for postoperative opioid prescribing in adult urologic surgery patients. The guideline has been implemented in clinical practice and researchers will continue to assess how provider prescribing patterns change in the future. “As urologists, we have an opportunity to be leaders in the drive to curb excessive opioid prescribing, and we are committed to providing patients with excellent postoperative pain control while also acknowledging the current public health crisis,” said Ziegelmann.
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SINCE 1894 building COMMUNITY Northwest Family Physicians feel atHOME SINCE 1894 YOUR PA (Northwest Family Clinics) and BRIDGE North Memorial Health have entered BETWEEN BETWEEN feel atHOME refresh engaging HOSPITAL & into a formal affiliation agreement HOME buildingCOMMUNITY after a long history of collaboration. tradition of caringenrichingLIFE “This formalized partnership North Memorial Health Announce Partnership
with North Memorial Health will allow Northwest Family Physicians to continue to do what we do best as an independent family physician group while adding more resources to our practice,” said Chris Stuart, MD, president and chief medical officer of Northwest Family Clinics. Northwest Family Clinics has three locations—in Rogers, Plymouth, and Crystal. “By formalizing our connection to this provider group, we are
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demonstrating our belief that customers benefit when they have more choices,” said J. Kevin Croston, MD, chief executive officer of North Memorial Health. “Preserving independent provider practices and health care systems—like Northwest Family Clinics and North Memorial Health, respectively—is part of our commitment to unmatched customer service.”
Regina Hospital to Offer Virtual Neonatal Care Through Children’s Minnesota A new virtual care partnership with Children’s Minnesota will allow physicians at Regina Hospital in Hastings, part of Allina Health, 24/7 access to neonatal care specialists at Children’s. When deemed appropriate, Regina Hospital physicians will hold an audio/video consultation with a neonatal clinician at Children’s. Clinicians from both systems will then collaborate on the care management of newborns requiring acute
stabilization after birth and determine whether the baby needs to be transferred to Children’s Neonatal Intensive Care Unit for further care. “By allowing the Children’s neonatal specialists to actually see the baby, we’re confident that we’ll be able to keep and serve more families here, in our own community,” said Julie McGary, RN, manager of Regina Hospital’s Family Birthing Center. “We take excellent care of these babies and will send them to Children’s Minnesota for even more specialized care if necessary. Once it is determined a higher level of care is needed, safety and efficiency of the transport are also improved using the virtual care process.” This is the second virtual partnership between Children’s and Regina Hospital—they previously partnered on emergency virtual care in 2016. They may explore expanding the partnership to other departments in the future. Care navigation will be based at CentraCare Health–Long Prairie. St.
Cloud Hospital will continue to be the telestroke hub site for the network, with specialty providers on staff to perform the services via telehealth, as well as 24/7 information systems support. “Rural Minnesotans often face unique challenges when it comes to getting the health care service they need,” said Sen. Tina Smith. “That’s why I pushed the Health Resources and Services Administration to fund an initiative at CentraCare Health that would expand stroke care to more rural areas through telehealth. I’m glad to see that this project was funded and that more people in Central Minnesota will have access to these critical services.”
Fraser Receives $2.6 Million to Build Woodbury Clinic Fraser has received a $2.6 million grant from the Peter J. King Family Foundation to support the building of the Fraser Woodbury Clinic, which will be Fraser’s seventh clinic location. According to Fraser, there is
a huge demand for autism and mental health services in the Twin Cities, especially in the east metro where there are few providers. The 27,000-square-foot clinic will include specific lighting, acoustics, and design features to enhance treatment outcomes. “This is the first autism project, worldwide, designed based on quantitative perceptual building performance standards focused on the hypersensitivity of children and adults on the spectrum,” said Steve Orfield, president of Orfield Labs, a special advisor on the project. “The building is not imposing, institutional, or perceptually noisy; the intent was to not activate any area of hypersensitivity or to provide an experience of non-familiarity.” The clinic will provide autism treatment, early childhood mental health treatment, and pediatric therapy services. It is scheduled to open on June 25. Fraser estimates that more than 1,200 families will be served at the new clinic in the first year.
V Autism and Obstructive sleep apnea are now approved conditions V
HAVE YOU REGISTERED WITH THE MINNESOTA MEDICAL CANNABIS PROGRAM? Registration can be done online; there is no fee and it takes only a few minutes. Visit the registry website: mn.gov/medicalcannabis Your account will provide access to medical cannabis purchasing information from patients you certify. Once you are registered, you will be able to certify patients with a variety of conditions, including: • Cancer, Glaucoma, Tourette Syndrome, HIV/AIDS, and ALS
• Inflammatory bowel disease, including Crohn’s disease
• Seizures, including those characteristic of Epilepsy
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Cannabis Patient Centers are now open to approved patients in Minneapolis, Eagan, Rochester, St. Cloud, Moorhead, Bloomington, Hibbing, and St. Paul.
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Many patients have reported improvement in their health status from medical cannabis — some describing dramatic improvements. Smoking cannabis is not allowed under the program. Visit our website for educational resources about cannabinoids and the endocannabinoid system and for scientific literature on the efficacy of medical cannabis in treating certain conditions.
See our website for a detailed first year report. mn.gov/medicalcannabis
JUNE 2018 MINNESOTA PHYSICIAN
Laura Niedernhofer, MD, PhD, and Paul Robbins, PhD, have been named leaders of the University of Minnesota Medical School’s newly founded Institute on the Biology of Aging and Metabolism (iBAM), which is pursuing the goals of understanding the molecular events that lead to aging and developing molecular tools to influence lifespan, healthspan, and quality of life. Niedernhofer has accepted the role of director and Robbins has accepted the role of associate director. Both are internationally recognized experts in the molecular and cellular basis of aging, and both come from the Scripps Research Institute in Jupiter, Florida. They joined the faculty as tenured professors in the department of biochemistry, molecular biology, and biophysics in June. Niedernhofer earned her medical degree and PhD in biochemistry at Vanderbilt University School of Medicine in Nashville, Tennessee, and Robbins earned his PhD in molecular biology at the University of California, Berkeley.
The Minnesota Orchestra explores musical expressions of peace, freedom and reconciliation in a celebration of Nelson Mandela's Centenary that concludes with a five-city tour of South Africa.
Halena Gazelka, MD, anesthesiologist and chair of the Mayo Clinic Opioid Stewardship Program, has been appointed to serve on the newly established Pain Management Best Practices Inter-Agency Task Force by U.S. Department of Health and Human Services Secretary Alex Azar. The task force was established by the Comprehensive Addiction and Recovery Act of 2016 and will work to identify inconsistencies in pain management best practices among federal agencies and propose solutions to resolve the inconsistencies. Gazelka’s career has focused on pain and palliative medicine, both in patient care and research. She serves in multiple capacities that focus on opioid management, acute and chronic pain management, neuromodulation, intrathecal drug delivery systems, spine care, and cancer pain management. She earned her medical degree at the University of Minnesota Medical School.
Alvaro Sanchez, MD, has been named Ridgeview Medical Center’s first chief medical officer. Sanchez, an internal medicine physician, has more than 25 years of clinical and administrative experience, with a focus on evidence-based population management, wellness initiatives, medical operations, and patient experience. Most recently, Sanchez held the position of chief medical officer for the VA Midwest Health Care Network, where he served as the senior physician in an integrated system of nine hospitals, 69 community-based outpatient and outreach clinics, eight community living centers, and four residential rehabilitation treatment programs. He has also served as medical director for Medica and UCare, as well as Park Nicollet. Sanchez also served in the Minnesota Army National Guard as Medical Corps Officer in positions of increasing responsibility, including State Surgeon. He earned his medical degree from Pontifical Javeriana University in Bogota, Colombia.
Family Concert: Courage and Triumph Sat Jul 14 2pm
Vänskä Conducts Beethoven’s Fifth Thu Jul 19 7:30pm
Celebrating Mandela at 100 Fri Jul 20 8pm
International Day of Music FREE EVENT! Sat Jul 21 Noon-Midnight
Beethoven’s Ninth Symphony Sat Jul 21 8pm
Roderick Cox Conducts Symphony in 60 Fri Jul 27 6pm & 8:15pm
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MINNESOTA PHYSICIAN JUNE 2018
Creating new ways to deliver value James Hereford, MA Fairview Health Services Coming from California to Minnesota, what are the biggest differences you have encountered in the respective health care delivery systems?
are the heart and soul of our clinical programs, to organize, clarify, and align our health system to make the changes that help us realize our incredible potential.
I’ve observed a difference in orientation for the health systems. Minnesota health systems are oriented toward and committed to community and are very focused on collaboration with each other to advance common goals for the community. This collaboration yields better outcomes for our community. You don’t see as much collaboration among the health systems in California.
How about the practical considerations of such a large merger, such as integrating electronic health records, allocating physical resources, coordinating care teams, etc.?
The practical aspects of integration take time and investment. In many ways, you are ready to work as one organization long before you are able to integrate the systems that help support you in working as one. That is a reality of integrations, and is certainly true of ours. The timing and size of this integration mean that we are looking at and reenvisioning many aspects of how we operate. We’re not just integrating one into another. We’re building something new together, and that is exciting and energizing.
Is there anything different in how California and Minnesota health care consumers approach health care?
What can you tell us about incorporating the culture of a faith-based organization like HealthEast into the Fairview business model?
We have the opportunity to do something very special here.
The key word is “consumers.” Health care consumers everywhere want and need a different health care experience. Today’s health care consumers expect easy access, simple processes, and clear pathways. They are digitally enabled. They order groceries online, bank online, and connect with almost everything they need online. In health care, we haven’t consistently provided that kind of experience. Too often, the burden falls on the physician and clinical team to put in heroic efforts to create that exceptional experience, and the team isn’t as supported as I think they can and should be to meet and exceed the health care consumer’s expectations. Creating and enabling a consumer-centric model and the systems to support it are key focus areas for us.
Though talks of the merger between Fairview and HealthEast predated your arrival, jumping right into the heavy lifting
What can you share about your experience
of such a far-reaching project must have
becoming CEO of Fairview?
been overwhelming. What can you share
I came to Fairview because I saw the tremendous potential of this health system. As I came on board, I likened it to having a Ferrari in the garage, but when you open the garage door you find your Ferrari is in parts, strewn across the garage floor. This is a health system that has all the capabilities and parts required to be a truly great, nationally recognized health care delivery system, and the people are in place to help make that happen. My focus is on working collaboratively with our teams and engaging our clinicians, who
with us about that experience?
JUNE 2018 MINNESOTA PHYSICIAN
Frankly, it was not as difficult as most efforts of this size are, thanks to the alignment of the two organizations and the people who have come together. We’ve all seen the tremendous potential we have together, and there has been a focused determination to realize the potential of the combination. Both organizations have faith-based roots, and that translates to a set of values that make it much easier to align on our common purpose.
Fairview, like HealthEast, has a long history of faith connection. The first Fairview hospital was created by the United Church Hospital Association in 1906. We have dozens of Lutheran congregations with whom we still work closely as a health system. Over time, the system nurtured relationships with other faith-based groups as the connections within our community evolved. What we’ve found in bringing HealthEast and Fairview together is that our cultures share a deep rootedness in mission that comes from those roots as faith-based organizations. This means we have a shared values-based anchor for the decisions we make and the way we approach caring for our communities. Fairview has had a long relationship with the University of Minnesota. What is the status of that relationship?
Our relationship with the University has been and continues to be about connecting the value of world-class clinical research and education to a broader care delivery system. We are currently refining the next phase in what has been a long partnership and looking at how to best realize our collective vision and potential
as a care delivery system and as an academic institution. I believe we have the opportunity to do something very special here in bringing the strengths of both institutions together in new ways to help lead the changes that will make health care better now and into the future. Given all the dynamics at play in health care, it is critical that the next phase of our relationship supports us in operating as a seamless and high functioning system that meets the needs of the patients, families, and communities that we serve, and that makes care at every level easier to access and simpler to use. What insight does your experience in working with Stanford Health Care bring to working with the University of Minnesota?
At Stanford, I grew to really appreciate the important role academic institutions play in the overall health care ecosystem. They are critical for advancing medicine. I also grew to appreciate the pressures those institutions feel, even Stanford, to keep pace with change and innovate in order to remain relevant in that role. Appreciating all the participants in the health care ecosystem, what they bring, and what they need is critical to our
“The Hub helped me get back on Social Security so that I could pay my bills while I continue to work on my health.”
collective success in continuing to meet the health care needs of the people we serve. We are hosting a conference this fall on consolidation in health care, examining cost and quality issues. What can you tell us about this topic?
With any consolidation, you need to know why you’re combining and what you hope to achieve for those you serve. Some consolidation is really about trying to compete more effectively in old ways. Other consolidations are about trying to create a platform for innovation to create new ways of delivering value to the market. Obviously, I am much more a fan of the latter than the former. More or bigger of the same is not going to address the key issues we face. New thinking is going to be required. We can see this in the digital space as the promises of new technology meet the limitation of our current technology platforms. What are the most important changes you
touches. I believe health systems like ours are the most compelling form of health care delivery. We have the opportunity to connect people to the care they need, when they need it, where they need it, and how they need it. We have all the pieces and parts, and this is our time to put them together in a new way. Too often, our clinicians have experienced the system as a barrier to delivering care. We’re working to become a system enabled by technology and a better understanding and management of our own processes. We’re working to become a system that helps clinicians maximize their time on what they are uniquely trained to do. Ultimately, we’re working to “own” the complexity of health care for our patients and meet and exceed their expectations of how health care can work for them. James Hereford, MA, is president and CEO of Fairview Health Services. Prior to joining Fairview, he served as chief operations officer at Stanford Health Care. Previous roles included chief operations
hope to facilitate at Fairview?
officer at the Palo Alto Medical Foundation and a
I am inspired each day to continue to work toward delivering more fully the promises of the integrated health care system to everyone it
Care Delivery System.
series of leadership roles with the Group Health
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MINNESOTA PHYSICIAN JUNE 2018
3Elder abuse from cover one form of abuse at a time or over time. For this reason, intervention on behalf of an older victim is critical. What begins as one form of abuse may well result in a victim experiencing other forms as well. Each experience of abuse, neglect, and financial exploitation results in negative consequences to the health and quality of life for victims of crime.
A widespread problem
Consistent with statistics about where elder abuse happens, we also know that perpetrators are most likely to be the adult children or the spouse of an older victim. Risk factors for perpetrating abuse include underemployment or unemployment, a prior history of abusing or trouble with the police, or substance abuse or gambling problems. Abusers often live in their victims’ homes, and may claim to be “providing care” for the victim. Perpetrators can be male or female, and are more likely to be in a relationship of trust with a victim.
Prevalence statistics are startling: one in 10 adults Warning signs of physical abuse and neglect include Intervention on behalf of over the age of 60 will experience abuse, neglect, or bruises; pressure marks or sores; broken bones; an older victim is critical. exploitation. The risk doubles when an individual burns; weight loss and malnutrition; poor hygiene; is cognitively impaired, according to the NCEA. bite marks; difficulty walking or standing; stained, Changing demographics increase the urgency of torn, or bloody clothing, bedding, or furnishings; or this issue; census data shows that 9 percent of adults unexplained sexually transmitted infections. Warning over the age of 65 have some cognitive difficulty signs of financial abuse can include unpaid bills, abrupt (doubling their risk) and that 36 percent have some changes to documents (which can include changes to disability. Any disability is a risk factor for abuse, neglect, or exploitation. health care directives or power of attorney for health care), or uncertainty or Elder abuse also takes place across settings. Contrary to popular belief, it occurs more frequently outside of congregate living settings, where older or vulnerable adults may be isolated. In Minnesota alone in 2016, county social services investigated 23,171 reports of maltreatment occurring in independent living settings: private homes, apartments, or other private residences. However, abuse also occurs in licensed provider settings, including in long-term and acute care settings.
concern about financial circumstances. These warning signs are particularly concerning if they are occurring in patterns, or simultaneously. For older patients you might see in your practice, the National Clearinghouse on Abuse Later in Life (NCALL) notes some specific warning signs you may notice. These include isolation, which may be self-imposed or may be imposed upon an older victim by a perpetrator, and repeated “accidental” injuries (research by Dr. Simon Dong, published in JAMA, notes that elder victims visit emergency departments twice per year on average, and are twice as likely to be hospitalized). Older abuse victims may present as “difficult” patients, and may present with vague but chronic complaints. Significantly, older victims may also have considerable difficulty following through on treatment plans, or may miss appointments. Because older victims often rely on their abusers for rides to and from doctor visits, or for assistance filling prescriptions, these needs often go unmet.
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In Minnesota, physicians are among the professionals who are mandated reporters of suspected maltreatment of vulnerable adults. The language of the governing statute (Reporting of Maltreatment of Vulnerable Adults, 626.557–626.5572) indicates that a report should be made when “a mandated reporter … has a reason to believe that a vulnerable adult is being or has been maltreated, or who has knowledge that a vulnerable adult has sustained a physical injury which is not reasonably explained.” Mandated reporters are directed to the common entry point, which is, in Minnesota, the Minnesota Adult Abuse Reporting Center (MAARC). Mandated reporters make their reports either orally by phone, or via the MAARC online reporting tool available on the Department of Human Service’s website. Failure to report suspected maltreatment results in liability for any resulting damages caused by that failure. A report made in good faith results in immunity for any civil or criminal liability that might otherwise result from report-making. Reporting is critical, not only because of the opportunity it affords older victims to get needed help and support, but also because the profundity of underreporting makes elder abuse a difficult problem to address at a systems level. An oft-cited study from New York demonstrates that for each case of
Many intervening systems are implicated when an older adult experiences abuse, neglect, or financial exploitation. Our patients and clients may have questions about how these systems interact to achieve stability, justice, support, safety, and all of the above. They will look to us as professionals for guidance in navigating these complex health and justice systems, and we provide the best service to our patients with holistic and collaborative responses to their questions. Holistic in recognizing that elder abuse is a systemic problem with varied solutions across experience, and collaborative in recognizing reporting obligations Physicians are well-positioned and working together to figure out who has the to be a solution to the answer a patient or client needs. The National Elder problem of abuse. Justice Roadmap describes elder abuse as “a problem with solutions!” Physicians are well-positioned to be a solution to the problem of abuse, neglect, and financial exploitation on behalf of their patients.
abuse known to programs and agencies, 24 cases were unknown. The causes of underreporting are broad and significant. For many older adults suffering from dementia or other cognitive or communicative impairments, self-reporting is simply not possible. Others are concerned about reporting on family members—and while all victims want abuse to stop, not all are comfortable sending a grandchild to jail. A Stanford University study cited additional factors that may prevent victims from engaging with systems and agencies: cultural and language barriers, fears that institutional care represents the only alternative to enduring abuse, and fear that abuse or exploitation may escalate with a report. Ultimately, many older adults simply don’t feel their report will be believed. Incredulity, resulting out of ageism, can be a significant deterrent to reporting in the first place.
There are some useful questions, strategies, and screening tools available to physicians to combat older patients’ belief that their report won’t be believed, and to assist in determining whether a patient is safe. First, be attuned to the risk factors for abuse, and sensitive to the possibility for patients experiencing those risk factors (including isolation). Second, if possible and in a setting that encourages an honest answer, ask whether patients feel safe, whether anyone is hurting them, or whether anyone is taking their money or property without their permission. If patients answer in the affirmative, ask follow-up questions that allow them to offer additional information. Third, peruse some tools: the Elder Abuse Suspicion Index (EASI), created in a primary care setting by Dr. Mark Yaffe, is a widely recognized tool that can help physicians determine whether to proceed with a report; it contains questions for physicians to pose to patients, and questions for physicians to answer independently. Additionally, Dr. Laura Mosqueda, Dean of the Keck School of Medicine at USC, has developed an Abuse Intervention Model (AIM) that can assist physicians in identifying and intervening on behalf of their patients who may be experiencing abuse. It is critical to approach responses to abuse in a collaborative and multidisciplinary manner, both within a care team and across systems that affect older victims. Experiences of abuse, neglect, and financial exploitation have devastating impacts on victim health, but responses involve not only health systems, but civil and criminal justice systems and social service systems as well. This systemic interaction can be complex for professionals, and overwhelming for older victims and families to navigate at times of significant stress. The more collaborative we can be, as professionals providing services to older adults, the likelier we will be to achieve and maintain safety for older victims of abuse.
Resources There are many tools and resources available to physicians and other members of health care teams to learn more about abuse, neglect, and financial exploitation, their impacts on older adults, and how best to prevent those crimes from occurring. In addition to resources and advocacy for patients and older victims provided by our adult protection and ombudsman systems, the Minnesota Elder Justice Center is available to offer support to patients and families with questions about abuse or maltreatment, and to provide technical assistance and training to professionals with questions about intervention, reporting, and systems responses.
Marit Anne Peterson, JD, is program director for the Minnesota Elder Justice Center and a member of the governing council of the Minnesota State Bar Association’s Elder Law section. She also served on the Olmstead Specialty Committee for the Prevention of Abuse and Neglect, and currently serves on the steering committee for Minnesota’s Working Interdisciplinary Network of Guardianship Stakeholders.
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3Housing as health care from cover
Prescribing—and paying for—housing
HCMC, welcomes patients experiencing homelessness to recover from their illness or surgery at Exodus Residence. Everyone was thrilled by the news that we had found a place for George to recover—everyone but George. For reasons that are still not clear, he was not willing to go to Exodus Residence to recover. He left the hospital Against Medical Advice (AMA), and I have not seen him since. But he has visited the ED about once a week since that time, usually brought in for intoxication. George had the best surgical treatment we have to offer, but addressing his acute problem was not enough.
The consequences of this disparity are staggering: in a 2014 paper describing homeless deaths in British Columbia titled “Dying on the Streets,” Condon and McDermid report that, in cold climates, homelessness can cut a person’s life almost in half.
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To move George and others like him from our hospital directly into stable housing, we presumed that the health care system would need to pay for at least a portion of that housing. The notion of a health care system paying for housing initially seems nonsensical, because budgets are already stretched to the limit by existing services. But the truth is that the health care system already pays to house the homeless in settings like the ED and hospital. The total charge for George’s three-day hospital stay was $93,000.
Where do we send a postop patient experiencing homelessness?
What was missing? George could improve many aspects of his life, but he lacked one key social determinant of health: stable housing. Without this basic necessity, how could George ever hope to address his other health concerns? This fundamentally unequal starting place—the fact that George starts every day on the streets—perfectly illustrates the health disparity created by homelessness.
The evidence-based literature shows that housing is an effective health intervention, but we, as providers, are frustrated by our inability to deliver that treatment. We want the ability to “prescribe housing.” To begin the journey towards that objective, Upstream Health Innovations (UHI), the innovation team for Hennepin Healthcare, asked the question: how might we prescribe housing to those who need it?
Fortunately, an opportunity exists to redirect this acute care spending to pay for housing, and the literature shows that housing the highest-utilizing patients creates health care savings. We also believe that providers will be more incentivized to do this when we move closer to value-based payment models that pay us to keep people healthy.
How much should housing cost? For health care to pay for housing, we needed to flip the standard model of building affordable housing. Traditional affordable housing projects start with the building design and then work backwards to raise the money. We flipped that model by starting with the dollars that are available and then designing the structures and services within that budget. In collaboration with the University of Minnesota School of Public Health, we interviewed every Medicaid health plan in Hennepin County, housing experts in every level of government, community partners who serve the homeless, and subject matter experts at HCMC. We estimated the expected health care savings from housing and reinvested all of those savings into the model, because most health plan leaders told us that they would need no return on investment from housing—just a solution that was cost-neutral, given the expected reduction in ED visits and hospitalizations. What health plan leaders really wanted from housing was dramatically improved health outcomes for their members. In addition to health care funding, the model also utilizes a reliable source of funding from the state of Minnesota. Finally, the model includes funding for supportive services to help individuals remain successfully housed. From this financial modeling, we learned that we would need to build and operate housing—and pay off the mortgage in five years—for less than $995 per month. Traditional affordable housing exceeds that monthly threshold. UHI, along with Thomas Fisher, MA, a professor at the University of Minnesota and director of the Minnesota Design Center (MDC), and his team, explored architectural innovations that could help the health care system house patients experiencing housing instability. We quickly learned that both existing affordable housing units and standard new construction techniques are too expensive for the health care system to afford and won’t meet our $995 price point with a five-year mortgage payoff. We need something beyond what we
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currently consider “affordable”—we need “extremely affordable” housing. Extreme affordability can be achieved through many strategies, including a smaller footprint using micro-units, shared resources, energy efficiency, new building practices, and innovative methods of property management.
A surprising key ingredient for success Many groups across the country use these microunits—minimally sized dwellings, sometimes singleroom structures—to house people experiencing homelessness, and we wanted to learn from these communities. We visited Community First Village (CFV), a tiny home village successfully serving the chronically homeless in Austin, Texas. We saw all the standard ingredients you would expect: affordable housing, supportive services, medical care, mental health treatment, chemical dependency services, and vocational training.
The bottom line
Health care providers know that housing is an important social determinant of health, and we long to provide housing for our patients by writing a simple prescription. The complexity of the situation is best captured by the stories of people who were placed in stable housing but ended up returning to the streets. We have learned that the dense social connections of a community are the key component that keeps people in stable housing. Housing the highest-utilizing As health care systems look at ways to house their patients creates health patients, they also need to evaluate whether their care savings. patients will be living in a place with intentional social connections. Join us as we design a system where we can write a prescription for both housing and intentional community.
But CFV demonstrated that the essential ingredient to remain successfully housed is a supportive community. During our interviews, we met many people who had previously obtained traditional affordable housing, but later ended up returning to the streets. Recall how we obtained a stable place for George to recover after his surgery, but that he chose to return to the streets after leaving AMA. Why would people turn down a stable place to live? Many of our patients have shared that they do not want to go to a place where they feel isolated from their loved ones or rejected by their new neighbors. At CFV, social connections are woven into every aspect of village life, so that residents participate as an integral part of the community and know that CFV is their home. The success of CFV taught us that we need to not only build extremely affordable housing, but also design an intentional community with supportive neighbors.
William E. Walsh, MD, is the deputy chief innovation officer for Hennepin Healthcare’s Upstream Health Innovations. He is also a board-certified and practicing facial plastic and reconstructive surgeon and an assistant professor in the Department of Otolaryngology–Head and Neck Surgery at the University of Minnesota.
Jon L. Pryor, MD, MBA, is the chief executive officer of Hennepin Healthcare and is a board-certified urologist. He is also a professor in the Department of Urologic Surgery at the University of Minnesota.
Pat, a woman who lives at CFV and struggles with bipolar disorder and cutting behaviors, showed me what “community” really means. Pat’s neighbors know her cutting behaviors start small and can escalate over time. But her neighbors also know that the first sign of trouble is when she cuts her hair. When one of her neighbors sees that she has taken a chunk out of her hair, the community rallies around her, and they also let the mental health center know. That support has always helped her to avoid more harmful behaviors. “Community” is really a dense network of people and social connections that accept you as a person—even your self-injuring behaviors—and rally around you with acts of kindness, expressions of concern, and offers to help.
Envision Community With this insight that both housing and intentional community are necessary parts of the prescription, “Envision Community”—a collaborative project under development by UHI, the University of Minnesota, and community organizations—was created to cultivate health through housing and community. In addition to featuring supportive micro-units that are truly affordable, we are also designing the social connections all of us need to make a place home. Our collaborative is holding targeted co-creation sessions to learn what types of political, financial, and community barriers exist, and how to overcome them. We are seeking partners with insights into these barriers to join us in designing and funding a pilot of Envision Community in Minnesota. MINNESOTA PHYSICIAN JUNE 2018
Value stream mapping Focusing on the patient’s experience BY CHAD FROST, BSME, BSEM
recent visit to the emergency department (ED) with my elderly father confirmed my belief that health care organizations can benefit from applying Lean Design principles—particularly value stream mapping (VSM)—to their main processes. Lean Design cconsultants view value from the eyes of the customer, and are starting to apply the key foundations of Lean thinking and architectural design by incorporating VSM approaches that make the patient experience a priority. VSM uses a diagram or flow chart to analyze and improve each step of a process (such as a patient visiting the ED) as either adding value or not adding value. Although this seems straightforward, the process itself and the paradigm shift required is a more complex task. Ultimately, value stream mapping will define how the patient perceives the value being delivered by the health care organization and allow decision makers to plan for and improve upon this value to increase patient satisfaction, reduce costs, and improve the throughput of their process.
A case study My father’s experience was typical of many ED visits. While lengthy
delays are to be expected in overburdened emergency departments—for understandable reasons, given unpredictable demands and the need to triage cases—I took this as an opportunity to consider the visit as a VSM case study focusing on the “customer” experience, just as I would for my clients. My value stream notes included: • A stop at the registration desk to check in, list symptoms, and confirm insurance. • Forty minutes in the waiting room to see the triage nurse, whose assessment took 10 minutes. • A return to the waiting room, where another 40 minutes went by until a nurse walked us to an exam room. The nurse took my father’s vital signs, which took about 10 minutes, and told us that the doctor would be in soon. • An hour in the exam room until the physician arrived, performed a 10-minute exam, shared her diagnosis, and ordered lab tests. • A visit from the phlebotomist, who took blood samples and then left. • A 45-minute wait for the doctor to come back with the lab results. She consulted with us on the diagnosis and course of treatment, which took 10 minutes, and told us we were done—but had to wait for the nurse to discharge my father, which took another 20 minutes. In total, the visit lasted approximately 245 minutes, or just over four hours.
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Patient vs. provider experience Many can relate to the experience my father had during his visit to the ED, and most of us have come to accept that it takes a long time to complete this process, but does it really have to be this way, or have we accepted it because it’s always been this way? Applying Lean to the ED process will yield better patient outcomes, faster cycle times, and higher patient satisfaction.
It’s interesting to note, however, that my father’s experience is completely different from what the staff and providers experienced during this same fourhour period. ED providers and staff experienced the process in episodes where they either provided direct service to my father (valued added, under the VSM model) or did not provide direct service (non-value added). Because providers and staff are so busy, it’s unlikely that they stop to consider what the patient is experiencing. This is where value stream mapping can be an important tool, because it visually illustrates the patient experience and lets staff and providers view the process from another perspective (the paradigm shift). A Lean health care consultant always asks a few simple starter questions to help their client understand the “value paradigms” they operate under while delivering service: “How well do you know your process from start to finish?” and “How do you know if your process delivers value to the customer?” Inevitably we get the same basic response: “I can’t be expected to know the whole process, but I know my part very well and I’m sure the customer values it because they continue to utilize our services, right?” Value stream mapping to page 164
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3Value stream mapping from page 14
Granted, not all of what staff and providers do can be considered direct care, but creating a VSM of a typical patient’s visit can make it easier to see where changes can be made to improve the patient experience.
Those answers provide key insights into how well our clients understand whether their overall process is truly generating value in the eyes of their patients, For the simplified value stream map in Figure 1, the biggest non-value or whether it adds costs that sap away profitability added time contributor seems to be waiting for the and reduce the perception of quality of care in the next process step. To reduce or eliminate some of eyes of the patient. For instance, how many times these wait times, some organizations have: does the patient need to answer the same questions • Allowed for mobile phone registration and or fill out the same forms before the organization’s data entry. systems have the information they need? What Applying Lean to the ED process • Performed basic triage in the waiting room. value comes from having nurses escort people from will yield better patient outcomes. process step to process step, when they could be • Moved patients immediately to triage rooms performing activities with higher value? What are or directly to exam rooms, utilizing RFID tracking tags and monitors placed strategically the risks of constantly moving the patient from step in the department to ensure the staff is aware to step versus bringing services to the patient? of the patient’s total time at each of the value A value stream map stream’s steps. Going back to my father’s emergency department visit, he experienced • Utilized navigators instead of nurses to assist patients to the exam room. intermittent value-added periods (i.e., vitals taken, labs secured, provider • Evaluated the staffing composition and scheduling to align with diagnosis, and discussion) and non-value-added periods (i.e., waiting, walking loading levels. to and from service areas, providing the same information multiple times). • Ensured that the lab IT systems communicate effectively with the ED’s IT systems, to reduce delays in reporting results.
His visit is broken down in a very simple value stream map, shown in Figure 1. Of the more than four hours that my father spent in the ED, only 45 minutes—about 18 percent—is considered a value-add by the patient. Health care clients are usually shocked to see how little of what they do when attending to a patient is really considered of value to that patient.
• Established remote labs closer to the ED to decrease cycle times on testing and analysis. • Allowed providers to discharge patients at the completion of the visit.
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â&#x20AC;˘ Reduced paperwork for the patient by educating the patient on the use of electronic records such as MyChart.
Chad Frost, BSME, BSEM, is a mechanical engineer and the director of Business Excellence at EAPC Architects Engineers. He is a certified Six Sigma Black Belt (which employs a methodology based on statistical analysis) and
A personal perspective Unfortunately, some of these solutions may not work in your ED, but therein lies the true benefit of value stream mapping. VSM makes the whole organization understand the flow process from a patient perspective, and establishes a starting point to begin improving it together. The payoff could be increased patient satisfaction, reduced costs, and improved throughput.
Lean practitioner, an ASQ-certified Lead Auditor for ISO 9001 Quality Management Systems, and a senior member in good standing with ASME and ASQ.
Simplified Value Stream Map of an ED Visit Register
Value added Non-value added 5 mins
Figure 1. A simplified VSM of my fatherâ&#x20AC;&#x2122;s ED visit, including steps in the process and designating value added and non-value added periods.
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Violence in the ED Planning and designing for safety BY ELIZABETH SCHULZE, AIA, LEED AP BD+C
orkplace violence (WPV) is a growing problem in health care, one that is “underreported, ubiquitous, and persistent,” according to the New England Journal of Medicine. A 2014 survey by the Journal of Emergency Nursing found that 76 percent of nurses experienced verbal or physical abuse from patients or visitors in the last year. And a 2015 study by the International Association for Healthcare Security and Safety Foundation discovered a 4 percent rise in hospital assaults in the previous year. WPV is especially common in the Emergency Department (ED). While nurses are the primary target, physicians are not immune. Approximately one-quarter of emergency medicine physicians reported being targets of physical assault in 2017. In Minnesota, the problem came to public attention in dramatic fashion in 2014, when an elderly patient at St. John’s Hospital in Maplewood was caught on security cameras rampaging through the hospital and attacking nurses with a metal rod. This event prompted the passage of the state’s Violence Against
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Health Care Workers Act (Minnesota Statute 114.566), which requires hospitals to design and implement preparedness and incident-response plans for violence that occurs on their premises, and to review those plans annually. While creating incident-response plans is important, more can be done to prevent incidents in the first place. EDs can become safer places to work, if these facilities understand the risk factors of WPV, assess their current vulnerabilities, and take steps to design physical spaces and hospital policies that respond proactively to those risks. The following article will shed light on the warning signs of WPV, offer an overview of risk-assessment tools available, and give physicians insight into design strategies that should be considered to improve staff safety in the ED.
Warning signs The Minnesota Department of Labor and Industry is a good local resource for information about the causes of WPV and for tips on complying with the state’s Violence Against Health Care Workers statute. Using the department’s free consultation service, MNOSHA (Minnesota Occupational Safety and Health Administration) Workplace Safety Consultation, employers can also learn about workplace hazards via on-site workplace violence consultations. In a video message to trustees of the Minnesota Hospital Association, MNOSHA’s Vikki Sanders stresses that WPV can happen anywhere. It’s not confined to urban locations, but happens thousands of times a day across the nation in every type of health care setting. Although your response will depend on your specific threats, all health care environments should be considered targets. Sanders also disputes the myth that WPV events are unpredictable and therefore can’t be prevented. On the contrary, in at least 85 percent of WPV incidents, there are clear warning signs. These include: 1. Long wait times and delays. 2. Volatile or aggressive people impacted by stress or substance and alcohol abuse. 3. Interactions between families and visitors.
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4. Unrestricted 24-hour service and unrestricted movement of the public. 5. Overcrowded, uncomfortable waiting areas. 6. Effects of “negative progression” sequencing, which occurs when a patient is sent back to the lobby after registration and triage, only to wait a second time. 7. Poorly lit corridors, rooms, or parking lots. 8. Lack of staff training and lack of policies for preventing/managing WPV risk situations. 9. Inadequate security. 10. Working when understaffed. If any of these factors are present or common in your ED, it is worth considering policy and/or architectural design changes to address them.
Three steps to a safer ED Preparing for the threat of WPV consists of three general steps: Assess your risk. Resources abound to assist health care organizations in understanding their risk areas and implementing preventative measures, from the National Institute for Occupational Safety and Health (NIOSH), the Joint Commission, the federal Occupational Safety and Health Administration (OSHA), and the American Hospital Association (AHA). The American Society for Healthcare Risk Management (ASHRM)’s Healthcare Facility Workplace Violence Risk Assessment Tool is one of the best, most succinct tools available. It offers a number of checklists, covering both proactive prevention and reactive response to WPV stemming from actions by patients, visitors, staff, and even physicians.
Parking. Emergency departments should have separate parking outside a walk-in entrance. All parking and ambulance entrances should be well lit, easy to exit, and have security surveillance. As the emergency department often becomes the hospital’s default entrance after hours and on weekends, additional security support should manage these areas at the ED portal. Entrances should be positioned at an angle from driveways to prevent intentional or accidental ramming or vehicular intrusion.
Many health care workers accept violence as part of their jobs.
The ASIS International Workplace Violence Prevention and Intervention Standard is longer and more comprehensive. No matter which tool you choose, it may be helpful to enlist an expert consultant to help. Address policy concerns. With risks assessed, a hospital-wide response to WPV must include a wide range of representatives, including nurses, physicians, security experts, local law enforcement, top-level administrators, facilities managers, and design professionals. In addition to policies and procedures for preventing and responding to WPV incidents, steps must be taken to create training and maintenance policies, as well as reporting and record-keeping mechanisms. According to a 2014 article in the Joint Commission’s EC (Environment of Care) News, many health care workers accept violence as part of their jobs, and “when something happens, they take care of it—but they don’t mention it to anyone.” Reporting is a key component in growing a robust, continually improving response to WPV. Collaboration with law enforcement is equally critical. The Minnesota Department of Health recommends scheduling routine operational meetings between law enforcement and health care teams. They offer a “collaboration road map” tool with evidence-based recommendations and standards for how health care should interact with law enforcement. Design against threats. OSHA’s comprehensive approach to any workplace hazard focuses on “engineering away the harm.” That means embracing design solutions that either remove a hazard from the workplace, or create a barrier between the worker and the hazard. In architecture and interior design, these goals can be achieved through a variety of means, from using design elements that provide a peaceful, calm environment, to more structural changes such as improving lines of sight within and between hospital areas. Simple steps—such as adding additional exits or partitioning off areas to protect valuable equipment in the event of a violent event—can also help.
Hot spots While each ED is different, there are generally five areas that can be thought of as “hot spots” where design decisions can help engineer away the harm:
Entry zone/waiting areas. Public and private spaces in the ED waiting area should be clearly delineated. Designers should pay special attention to sight lines and visual access to the entrance from registration, triage, and security. Duress alarms and lock-down activation buttons should be placed at strategic locations, such as central workstations. Seating areas should be arranged to allow free movement of people in the case of an evacuation, and to avoid potential entrapment or blocked egress. To mitigate and reduce the stress induced by long wait times, lighting and color schemes that are welcoming and have a calming effect should be used. Designers should maximize access to natural daylight, while taking precautions to avoid public scrutiny of the waiting area. Respite areas, TVs,
Violence in the ED to page 424
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Predesign in health care construction A critical first step BY JASON R. GRABINGER AND RICHARD P. ENGAN, AIA, CID, LEED AP
he difference between life or death for your patients often hangs on the health of your medical facility. Imagine a small, critical access medical facility that is vital to its community. The facility serves not only the residents of its community, but also individuals from a surrounding radius of many miles. Your patients rely on this medical facility, whether they have a health crisis or an accident. Imagine that this facility has become unable to adequately serve regional residents due to its age, size, or any number of other factors. Facility leaders know it needs improvements, but the range of possibilities feels overwhelming. Several questions loom: How can space be made for the medical technology that patients and physicians now require? How can the facility’s layout make it easier for patients and their families to find what they need? How can it be made more efficient for staff—especially at times of day (or night) when only a handful of medical professionals must run the entire facility?
Predesign is the critical first step in the process of solving these and a host of other design challenges. It can be difficult to navigate this process; collaboration with a skilled architect or medical facility planner is crucial.
Predesign 101 The core purpose of the predesign phase of any building project is to consider the big picture over the long term. Using a common-sense approach, a skilled architect facilitates the process of pooling stakeholders’ knowledge and experience, achieving a balance between meeting today’s needs and developing a vision for the future. Stakeholders include physicians, facility management, nurses, caregivers, specialty departments, patients, and families. The needs of each facility are unique, as is the vision for meeting future demands. The predesign phase is vital because it will deliver a design that provides a longer return on investment, improved medical care, and more successful recruitment and retention of medical staff. The average individual is not fully aware of all that is considered for a building plan. Architects ask several important questions to guide health care leaders through the predesign phase. Leaders must consider the why, who, what, where, when, and how of a building project. Some of these questions include, but are not limited to: • Why is the project being considered? • What are the needs of each department to best serve patients?
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JUNE 2018 MINNESOTA PHYSICIAN
• What is the desired outcome, today and in the decades to come? • During construction, what considerations will need to be made and who will be in charge? • Where will the necessary resources and finances come from? • How do the needs align with the budget? • How can the facility be designed to provide the most options for future adaptability? • Who are the stakeholders? • What are the responsibilities of the building owner and operator in a building project?
Predesign studies There is no clear-cut process for the predesign phase. Depending on the specific project, it usually begins with one of several studies. These studies can change or overlap as more information is gathered. A brief explanation of several study types: Program studies. The goal of a program study is to examine how a facility is used, including work processes, procedures, and flow. Departmental organization is considered, along with the details of patient care—what currently works well, and what could work better? The question to answer with a program study is, “How is the medical staff doing what they do now, and what would improve it?” Developing this baseline knowledge is the foundation of success.
Facility studies. This predesign component focuses on the physical Opportunities through predesign building itself: the building’s current general condition, age, systems, Once one or more of these studies are complete, the predesign process enclosure, finishes, and ability to adapt to rapidly changing technologies addresses several questions to gain a clearer vision of the opportunities and challenges presented by the project: and processes. Original construction documents and past additions or renovations are examined. Staff are consulted Should we re-use, renovate, and/or add on to regarding how the building meets their needs, what we have? and how it does not. The facility study is meant to Should we build a new facility entirely? If so, determine an answer for the question, “How does what property or assets do we own or could we buy? the facility work now, what is its condition, and There is no clear-cut process What factors must be considered to make these how could it be improved?” for the predesign phase. decisions? These factors could include: Visioning studies. These studies take a bird’s • Up-front financial costs, such as purchasing eye view of the facility and include questions such as: land, purchasing existing building(s), or • What do we need the facility to accomplish? renovating or adding on to existing buildings. • What is our vision for the future? • Ensuring continued services during the • What are the opportunities? building project, including where services will continue and whether the project can be phased to facilitate services. It takes a great deal of experience and skill to facilitate this study, including having a finger on the pulse of medical advances in both care and technology. Every building project must consider the future. Too often, medical facilities have been designed, renovated, or added on to for a purpose or particular technology that is too specific and short-sighted to remain in effect as it becomes obsolete. A visioning study is part of the process to design a facility that is highly adaptable, eliminating the potential need for further major building projects and ensuring that it remains on the cutting edge of both technology and patient care.
• Long-term financial costs, including the cost to operate and maintain each design option, HR costs to staff each design option, and any available tax rebates, subsidies, etc., related to each design option. • The long-term flexibility provided by each design option. Health care delivery technology changes rapidly, so effective hospital Predesign in health care construction to page 404
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MINNESOTA PHYSICIAN JUNE 2018
HEALTH CARE ARCHITECTURE
Hennepin Healthcare Clinic & Specialty Center Type of facility: Clinic and specialty center Location: Minneapolis Ownership organization: Hennepin Healthcare Architect/Interior design: BWBR Engineering team: Dunham Associates (mechanical and electrical engineering), Ericksen Roed & Associates (structural engineering), and Loucks Associates (civil engineering and landscape architecture) Contractor: M.A. Mortenson Company Completion date: April 2018 Total cost: $221 million Square feet: 377,000
eorganizing nearly two million square feet to offer centralized and accessible care for people who need convenient access to a doctor, same-day surgery, or cancer treatment, Hennepin Healthcare opened a new Clinic & Specialty Center (CSC) that consolidates over 40 primary and specialty clinics formerly spread across nine buildings. The 377,000-square-foot building marks the biggest expansion in its history for the Twin Citiesâ&#x20AC;&#x2122; largest teaching hospital. The CSC building includes six floors of clinics and services, and two levels of underground pay parking for patients and family. The building houses primary and specialty care, physical and occupational
JUNE 2018 MINNESOTA PHYSICIAN
therapy, a same-day surgery center with five operating rooms, and four GI/endoscopy rooms. The clinic is also home to a cancer center with radiation therapy, outpatient imaging center, womenâ&#x20AC;&#x2122;s imaging, and skyway and tunnel connections to the rest of the Hennepin Healthcare campus. In addition to the new facilities, BWBR also designed a new, second helistop, located on top of the building housing the Hennepin Healthcare emergency department, operating rooms, and intensive care units, directly across the street from the Clinic & Specialty Center. The new helistop doubles the capacity to receive trauma and critical care patients by air and reduces transport time into the hospital.
Minnesota Physicianâ&#x20AC;&#x2122;s 2018 Health Care Architecture Honor Roll recognizes 11 outstanding projects. This yearâ&#x20AC;&#x2122;s Honor Roll includes new or renovated clinics, hospitals, and a residential hospice and respite care home for children, at sites across Minnesota and in Wisconsin. Minnesota Physician Publishing thanks all those who participated in the 2018 Honor Roll. We received a lot of impressive nominations! By Richard Ericson
MINNESOTA PHYSICIAN JUNE 2018 2017
HEALTH CARE ARCHITECTURE
CentraCare’s Long Prairie Hospital and Melrose Hospital Additions Type of facility: Critical access hospitals Location: Long Prairie and Melrose Ownership organization: CentraCare Health System Architect/Interior design: HGA Engineer: HGA Contractor: Mortenson Construction | McGough Construction Completion date: September 2017 | August 2017 Total cost: $29 million | $24 million Square Feet: 63,000 | 50,000
ompleted simultaneously, CentraCare’s Long Prairie Hospital and Melrose Hospital additions share an innovative planning approach to facilitate long-term flexibility. Both facilities employ a “universal platform” concept that minimizes space through centralized, universally designed rooms shared between departments. Rooms may serve as prep/recovery spaces for surgery during the day, then switch to ED spaces. The Long Prairie
facility translates the natural environment into the design, with exterior patterns of brick, metal panel, and glass echoing the patchwork of the surrounding fields, and corridors that focus interior views to the agrarian landscape beyond. The Melrose design focuses on the character of local lakes and recreational areas, highlighted through rustic materials and large-scale graphics of lake scenes and vegetation. Lobbies at both sites are bathed in natural light.
Hello Progress Advancing health and wellness in local communities is at the heart of our endeavors.
JUNE 2018 MINNESOTA PHYSICIAN
HONOR ROLL 2018
TRIA Orthopaedic Center Type of facility: Orthopedic and acute injury clinic, ambulatory surgery center, and physical therapy/rehab Location: Woodbury Ownership organization: TRIA Orthopaedic Center Architect/Interior design: RSP Architects Engineer: Dunham, MBJ, Westwood Contractor: Kraus-Anderson Construction Completion date: September 2017 Total Cost: $31 million Square Feet: 78,000
RIA Woodbury is the region’s first fully dedicated orthopedic urgent care center, with an innovative, patient-centric approach that showcases therapy and recovery. The center’s three-story glass atrium provides patients, caregivers, and even shoppers clear sightlines by day and a light box glowing with colored LEDs by night. The stacking of departments at each floor provides visual access to all departments. The clinic’s main floor includes a café, retail space,
orthopedic urgent care, and an acute injury clinic with a full scope of imaging services to assess musculoskeletal issues. Physical, hydro, hand, and concussion therapy services are on the second floor, down the hall from an indoor throwing lane, with retractable turf and a pitching mound for recovering athletes to practice throwing, kicking, or hitting while therapists monitor movement. The three full-size operating rooms are equipped with integrated surgical technologies.
MSPCommercial.net | 651.287.8888
HEALTHCARE REAL ESTATE Development, Property and Asset Management
MINNESOTA PHYSICIAN JUNE 2018
HEALTH CARE ARCHITECTURE
HealthPartners Neuroscience Center Type of facility: Specialty clinic Location: St. Paul Ownership organization: HealthPartners, Inc. Architect/Interior design: BWBR Engineering team: Dunham Associates (mechanical and electrical engineering), Ericksen Roed & Associates (structural engineering), and Loucks Associates (civil engineering and landscape architecture) Contractor: Kraus-Anderson Construction Completion date: January 2017 Total cost: $76 million Square feet: 174,000
he new HealthPartners Neuroscience Center is the largest freestanding neuroscience facility in the Upper Midwest, combining laboratories for clinical research and trials with nationally recognized programs for a variety of neurological disorders. Working together, BWBR and HealthPartners selected a site that affords high visibility and transparency, both into and out of the facility, to effectively remove the mysteries that surround neurological treatment. Challenged by cognitive/
memory issues as well as physical abilities, this unique patient population’s needs drove the center’s design. Oversized environmental graphic elements and textured walls—easier to remember than numbers—assist navigation. Spacious exam rooms accommodate patients’ mobility needs and feature large wall-mounted monitors. A garden seating area features paths, ramps, and steps to help patients learn how to walk with confidence in a real-world setting, including through seasonal transitions.
Strategic Real Estate Solutions, Driven by Your Mission CREATIVE PLANNING AND DESIGN SOLUTIONS FOR EFFICIENT, PATIENT CENTERED ENVIRONMENTS CONTACT: Mark L. Hansen, AIA, NCARB, LEED AP BD+C firstname.lastname@example.org 952.426.7400 www.MohagenHansen.com
JUNE 2018 MINNESOTA PHYSICIAN
Develop • Lease • Manage • Monetize www.hsaprimecare.com • 312.332.3555
HONOR ROLL 2018
Essentia Health St. Joseph’s–Pierz Clinic Type of facility: Health care clinic Location: Pierz Ownership organization: Essentia Health–Central Architect/Interior design: LHB, Inc. Engineer: LHB, Inc. Contractor: Gopher State Contractors, Inc. Completion Date: September 2017 Total Cost: $1.5 million (construction only) Square Feet: 5,000 Photography by Dana Wheelock
Telephone Equipment Distribution (TED) Program
ocated on the site of the Old Bank Restaurant, a local landmark in Pierz, Minnesota, this clinic incorporates elements of the original historic structure, with a design that fits into the local aesthetic. A raised roof with clerestory windows over the waiting area gives added height to the structure and enhances the lobby and reception spaces inside. Natural stone was used on the façade facing the prime intersection, while cementitious panels clad a majority of the rest
of the façade to reduce maintenance. Inside the building, stained glass panels from the original bank—which predated the restaurant itself— were incorporated into the design, separating the waiting area from the rest of the clinic. The clinic consists of seven exam rooms, one procedure room, shared rehab/outreach space, and a radiography room. Exam rooms are fitted with transom windows that permit natural light while maintaining visual privacy to patients.
Do you have patients with trouble using their telephone due to hearing loss, speech or physical disability?
Creating Healing Environments for 39 Years
If so…the TED Program provides assistive telephone equipment at NO COST to those who qualify. Please contact us, or have your patients call directly, for more information.
1-800-657-3663 email@example.com mn.gov/dhs/ted-program Duluth • Mankato • Metro Moorhead • St. Cloud The Telephone Equipment Distribution Program is funded through the Department of Commerce Telecommunications Access Minnesota (TAM) and administered by the Minnesota Department of Human Services
“We wouldn’t hesitate to work with Engan Associates again.” (Matt Reinertson, Heartland Orthopedic Specialists)
Contact us: (320) 235-0860 • http://engan.com MINNESOTA PHYSICIAN JUNE 2018
HEALTH CARE ARCHITECTURE
Allina Health Clinic, River Falls Type of facility: Health care clinic Location: River Falls, Wisconsin Ownership organization: Allina Health Architect/Interior design: BDH & Young Design Architecture Engineer: Loucks, Inc. Contractor: RJM Construction Completion date: June 2017 Total cost: $4.45 million Square feet: 13,606
onnected by “The Link,” an enclosed, 100-foot, climate-controlled corridor, the Allina Health River Falls Clinic is the most recent addition to the River Falls Area Hospital Campus. Both facilities are part of the Allina Health Care System, providing patients the added benefit of shared systems and close collaboration. Window accents and a curved front façade facing west add interest to this attractive single story’s brick
and architectural metal exterior. This medical facility was designed for future expansion and currently has 17 exam rooms, expansive surface parking, and a port cochere for easy patient drop-off. Built to accommodate the increased primary care and specialty care needs of the region, the clinic provides family medicine, pregnancy and women’s health services, and acupuncture at the Penny George Institute for Health and Healing.
Healthcare Planning and Design
Essentia Health Plastics and Skin Renewal Center; Duluth, MN
COLLABORATIVE SOLUTIONS. INSPIRED DESIGN. The LEO A DALY team brings a passion for designing spaces focused on the human experience.
Duluth, MN | 218.727.8446 Minneapolis, MN | 612.338.2029 Cambridge, MN | 763.689.4042 Superior, WI | 715.392.2902
JUNE 2018 MINNESOTA PHYSICIAN
Elizabeth Schulze, AIA, LEED AP BD+C Healthcare Market Sector Leader EOSchulze@leoadaly.com • 612.752.8733
HONOR ROLL 2018
Minnesota Eye Consultants Type of facility: Ophthalmology clinic and ambulatory surgery center Location: Woodbury Ownership organization: MSP Woodbury Medical, LLC Architect/interior design: BDH & Young Design Architecture Engineer: Civil Site Group Contractor: Welsh Construction Completion date: February 2018 Total cost: $12.35 million Square feet: 41,000
oodbury’s reputation as a growing health care hub made the undeveloped parcel at Tamarack Road and I-494 West an ideal location for the newest Minnesota Eye Consultants clinic and ambulatory surgery center. The innovative design employs a unique patient-centric ophthalmology model that includes a clientfocused clinic workflow layout, state-of-theart ophthalmology technologies and services,
and a spa-like atmosphere to increase patient enjoyment. The exterior consists of a mix of natural stone, brick, architectural metals, and large two-story vision glass accents, creating a contemporary and simple façade to match the relaxing feel of the interior design. One of the largest ophthalmology ambulatory surgery centers in the state, the site expands Minnesota Eye Consultants’ footprint and allows easier and more convenient access for its patients.
8 FORMS OF WASTE IN HEALTHCARE
CORRECTION OF DEFECTS
WASTED STAFF SKILLS
ARE YOU READY FOR CHANGE IN YOUR ORGANIZATION? EAPC incorporates LEAN process improvement and evidence-based design principles in the facility planning, design, and project delivery processes to eliminate waste in your current or potential new facilities. Chad Frost, Director of Business Excellence, LEAN Specialist | 701.775.3077 | firstname.lastname@example.org
www.eapc.net MINNESOTA PHYSICIAN JUNE 2018
HEALTH CARE ARCHITECTURE
Summit Orthopedics Type of facility: Orthopedics center and ambulatory surgery center Location: Eagan Ownership organization: Eagan Woods I, LLC Architect/interior design: Pope Architects Engineer: Civil Site Group Contractor: RJM Construction Completion date: February 2017 Total cost: $25.65 million Square feet: 72,279
odeled after their award-winning Vadnais Heights facility, the Summit Orthopedics building in Eagan houses a full-scale ambulatory surgery center with five operating rooms. The three-story outpatient clinic offers a full range of orthopedic services, as well as hotel-like care suites to provide a relaxing space for surgical recovery. Easily accessible and located just minutes from the MSP International Airport, Mall of America, and the retail and business hub
of Bloomington, this facility is an ideal orthopedic location for visitors from outside the metro area. When formulating the shell construction plan for the building, special considerations were made to minimize ambient noise from the airport. The building includes a drop-off canopy, large surface parking, and an underground garage. The facility’s interior design conveys a warm and welcoming atmosphere to ease and comfort patients throughout their visit.
What healthcare will look like tomorrow Will it be the private market, or is the best answer to expand MinnesotaCare? From nationally-known leaders and the Minnesota legislators that will decide your future.
July 11, 2018 - 8:30 AM - 4 PM · Cowles Auditorium, Humphrey Institute for Public Policy · U of M Conference Focus:
For those who want independence, learn how the marketplace is providing answers and hope.
Dave Racer, MLitt - Keynote and Emcee
For those who want to settle into a Managed Care System, see how the marketplace and expansion of Government-Care are competing. Learn what lawmakers believe is best for you, and then share your opinions with them.
Neil Shah, MD, FAAD, Clarus Dermatology Scott Martin, CEO - Remedy Analytics Dave Rusch, Vice President - Smart Choice MRI Charles Crutchfield, MD, Crutchfield Dermatology Greg Dattilo, CEBS (Fellow) - CEO of Dattilo Consulting, Inc.
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Our Sponsors: Remedy Analytics · Minnesota Independent Physician Association · Minnesota Physician - Patient Alliance Minnesota Association of Black Physicians · Association of American Physicians and Surgeons 301 19th Avenue South, Minneapolis · University of Minnesota · www.healthcare2020-conference.com For registration please go to www.healthcare2020-conference.com/register.html
JUNE 2018 MINNESOTA PHYSICIAN
HONOR ROLL 2018
Lifestyle Health by CentraCare Health Type of facility: Clinic and retail health Location: St. Cloud Ownership organization: CentraCare Health Architect/Interior design: RSP Architects Engineer: Dunham Associates Contractor: W. Gohman Construction Completion date: September 2017 Total cost: Not available Square feet: 6,392
ifestyle Health provides health and wellness amenities in a modern retail setting. Located in St. Cloud’s newly renovated YMCA, the space inspires health, wellness, and exercise, with a design intended to be approachable, innovative, and experiential. An Experience Bar, much like Apple’s Genius Bar, welcomes patients, providing out-ofpocket services at competitive prices. Floor to ceiling windows and inviting sliding glass
doors provide a modern, fresh ambiance. Once past the Experience Bar, adaptable rooms offer cross-functional “plug and play” tenant space, with coefficient-rated walls that absorb sound and establish private rooms for consultation or examinations. Onsite medical professionals are equipped to deliver multiple health care disciplines: weight management education, diabetes care, sports medicine and physical therapy, massage, acupuncture, and many more.
MINNESOTA PHYSICIAN JUNE 2018
HEALTH CARE ARCHITECTURE
Grove Circle Medical Building Type of facility: General care clinic and ambulatory surgical center Ownership Organization: MSP Maple Grove, LLC Architect/Interior design: Mohagen Hansen Architecture Engineer: Loucks, Inc. Contractor: Welsh Construction Completion date: February 2018 Total cost: $9.65 million Square feet: 30,000
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160 First St., SE, New Brighton, MN 55112 FreePeripherals Space Optics – VoIP Systems – Data Networks - Multi-Function Peripherals Free SpaceSystems Optics – VoIP Systems – Data Networks - Multi-Function Free SpaceSpace Optics ––Networks VoIP – -Data Networks - Peripherals Multi-Function Peripherals Free Space Optics –VoIP VoIP Systems Data - Systems Multi-Function Peripherals Free Space Free Optics Space –Optics –Systems VoIP Free Systems – –Data Optics Data – VoIP Networks - Multi-Function – Data Peripherals Networks - Multi-Function Peripherals Free Space Optics – VoIP Systems –Networks Data Networks - Multi-Function Multi-Function Peripherals
JUNE 2018 MINNESOTA PHYSICIAN
HONOR ROLL 2018
Crescent Cove Respite & Hospice Home for Kids Type of facility: Pediatric hospice and respite care home Location: Brooklyn Center Ownership organization: Crescent Cove Architect/Interior design: RSP Architects Contractor: Gardner Builders Completion date: December 2017 Total cost: $460,000 Square feet: 6,700 Mural art by Christi Becker Commissioned by Crescent Cove
rescent Cove is the first children’s residential hospice and respite care home in Minnesota, and only the third in the U.S. A transformation of an existing adult hospice facility formerly owned by North Memorial, the facility is located on lakefront property in Brooklyn Center on Twin Lakes. It combines the comfort and feeling of a home with the capabilities of an ICU to provide daily physical care, as well as emotional and spiritual support for families.
Existing rooms were reimagined to normalize life and to encourage play and sensory engagement. Working with Cushman & Wakefield and Gardner Builders as the contractor—and with the support of volunteers and donors—the project finessed the existing hospice facility into a home for making every moment count, to honor the end of life, and to provide emotional support and a sense of community that these children and parents need most.
Three patients. Who is at risk for diabetes?
When there are no signs or symptoms, you may not know until it’s too late. Act now. Screen your patients for type 2 diabetes. It’s easy. It’s covered. It will reduce their risk. • Refer your at-risk patients to a proven lifestyle change program and help cut their risk of developing type 2 diabetes in half.
1 in 3 adults are at risk!
• For patients who already have diabetes, send them to a quality diabetes self-management program to improve control and reduce complications. Find groups in Minnesota at www.health.mn.gov/diabetes/programs
Minnesota Department of Health DIABETES PROGRAM
MINNESOTA PHYSICIAN JUNE 2018
Systemic lupus erythematosus Research drives hope BY ERIK J. PETERSON, MD
ystemic lupus erythematosus (SLE) is a chronic autoimmune condition that may affect nearly every organ in the body. The term “lupus” was used first by thirteenth century physician Rogerius, whose patient’s erosive facial rash evoked for him images of a wolf’s bite. SLE can affect both sexes at any age, but women carry the diagnosis nine times more frequently than men. SLE prevalence in the U.S. stands at between 0.05–0.1 percent. African-American and other minority women of childbearing age are most frequently affected by severe disease that produces inflammatory damage to viscera. Discoid and subacute cutaneous lupus represent milder disease forms that may result in chronic skin changes, but SLE may cause permanent organ injury and even death. Clinical features of SLE can manifest in many organ systems, but no clinical indicators are specific for the diagnosis. The typically insidious onset of temporally disparate, non-specific symptoms and signs in SLE patients helps explain the notoriously lengthy period between symptom onset and establishment of diagnosis. Nevertheless, alert clinicians often pick up SLE by recognizing symptoms arising from autoimmunity affecting one or more of the three most commonly involved organ systems
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that affect a majority of patients: musculoskeletal (~70 percent), cutaneous (80–90 percent), and renal (50–60 percent). The hallmark “butterfly” rash, distributed over malar and submental skin, occurs in 50–60 percent of SLE patients. The presence of recurrent mucocutaneous lesions such as oral ulcers and bullous skin rashes also serve to place SLE on the differential diagnosis. Inflammatory arthritis, defined as two or more tender or swollen joints in the context of morning stiffness, afflicts more than two-thirds of SLE patients. An array of nephritic and nephrotic renal lesions can be found in up to 50 percent of patients. Importantly, SLE should be viewed as a waxing and waning, yet accretive condition, with patients typically “adding” clinical manifestations over months to years before and after the diagnosis is established.
Contributing factors The cause(s) of SLE remain unknown. Recent research has sharpened focus on a number of genetic and environmental factors that contribute to SLE. Deficiencies in genes encoding C2 and C4, components of the ancient host defense system of complement proteins, have long been known to predispose to SLE. More recently, genome-wide scans have identified at least 28 additional loci that increase SLE susceptibility. Given the autoimmune and inflammatory nature of tissue injury in SLE, it is not surprising that many SLE “risk” or susceptibility genes exert function within the innate and adaptive immune systems. Examples include Fc receptors, TNFAIP3, and Itgam, genes that regulate adhesion and activation of innate immune cells such as macrophages, as well as loci encoding certain transplantation antigens (e.g., HLA-DR3) that govern the activation of T lymphocytes. Environmental factors that may play roles in triggering or accelerating development of SLE include external stimuli like ultraviolet light, viral infections (including Epstein-Barr virus), and cigarette smoke. Internally, dysregulation of networked pro-inflammatory soluble molecules called cytokines is characteristic of SLE. In the early 2000s, researchers at the University of Minnesota (Drs. T. Behrens and E. Gillespie) were among the earliest to observe that a majority of SLE patients exhibit a characteristic blood “signature” of genes and proteins induced by type 1 interferons, a cytokine family critical for anti-viral host defense. Subsequent research showing that chronically elevated type 1 interferon has detrimental effects on animals with experimental SLE has supported the viability of interferon as a candidate therapeutic target. Indeed, advanced clinical trials of monoclonal antibodies that block type 1 interferon signaling have shown promise in treatment of refractory human SLE. Other cytokines likely play an important role in driving polyclonal B cell expansion and hypergammaglobulinemia, key perturbations in adaptive immunity that drive SLE. Excess B lymphocyte stimulator (BLyS) signaling through receptors on developing B cells promotes production of a huge array of immunoglobulins, including SLE-defining antibodies that react with “self” molecules such as double-stranded DNA and nuclear proteins. Recognition of Systemic lupus erythematosus to page 364
JUNE 2018 MINNESOTA PHYSICIAN
PRACTICE WHERE BEAUTY SURROUNDS YOU
Sioux Falls VA HEALTH CARE SYSTEM Family Practice Physician Join a provider-driven not-for-profit organization in our Cook, MN location. Work in a well-established, modern facility. Participate in on-call schedule, share in-patient and after-hours care, (no OB). BC/BE and current or eligible for MN license required. National Health Service Corps loan repayment potential.
WORK-LIFE BALANCE: • Competitive salary • Significant starting & residency bonuses • 4-day work weeks • 51 annual paid days off Ski, hike, run, fish, canoe, kayak, camp and more in nearby state parks, Boundary Waters Canoe Area, Voyageurs National Park and Superior National Forest.
Working with and for America’s Veterans is a privilege and we pride ourselves on the quality of care we provide. In return for your commitment to quality health care for our nation’s Veterans, the VA offers an incomparable benefits package.
The VAHCS is currently recruiting for the following positions:
Cardiologist Endocrinologist Orthopedic Surgeon Neurologist PACT
Physiatrist Psychiatrist Psychologist Pulmonologist
Emergency Medicine (part-time) ENT (part-time) Gastroenterologist (part-time) Urologist (part-time)
apply online at www.USAJOBS.gov
Please contact: Travis Luedke, Cook Area Health Services, Inc., 20 5th St. SE, Cook, MN 55723 email@example.com 218-361-3190
(605) 333-6852 ·
Urgent Care Physicians HEAL. TEACH. LEAD.
At HealthPartners, we are focused on health as it could be, affordability as it must be, and relationships built on trust. Recognized once again in Minnesota Physician Publishing’s 100 Influential Health Care Leaders, we are proud of our extraordinary physicians and their contribution to the care and service of the people of the Minneapolis/St. Paul area and beyond. As an Urgent Care Physician with HealthPartners, you’ll enjoy:
THE STRENGTH TO HEAL and get
back to what I love about family medicine.
Do you remember why you became a family physician? When you practice in the Army or Army Reserve, you can focus on caring for our Soldiers and their Families. You’ll practice in an environment without concerns about your patients’ ability to pay or overhead expenses. Moreover, you’ll see your efforts making a difference.
• Being part of a large, integrated organization that includes many specialties; if you have a question, simply pick up the phone and speak directly with a specialty physician • Flexibility to suit your lifestyle that includes expanded day and evening hours, full day options providing more hours for FTE and less days on service • An updated competitive salary and benefits package, including paid malpractice HealthPartners Medical Group continues to receive nationally recognized clinical performance and quality awards. Find an exciting, rewarding practice to complement all the passions in your life. Apply online at healthpartners.com/careers or contact Diane at 952-883-5453 or firstname.lastname@example.org. EOE
To learn more, visit healthcare.goarmy.com/kb60
©2010. Paid for by the United States Army. All rights reserved.
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3Systemic lupus erythematosus from page 34 the BLyS pathway’s clinical importance in SLE led to the 2016 FDA approval of the first novel therapy for SLE in half a century. Belimumab, a monoclonal antibody that interferes with BLyS signaling, has found utility in the clinic, especially for SLE patients with difficult-to-manage skin or joint disease.
fatigue. Allied providers in physical and occupational therapy, as well as social workers, also play critical roles in not only helping patients maintain financial and social independence, but in enhancing patient ability to effectively engage in work, parenting, and physical activity while coping with illness. Non-medical organizations, such as the nonprofit Lupus Link Minnesota, aim to serve those living with SLE by offering education, promoting awareness, and funding research grants and fellowships. They work to increase awareness in the hopes of expediting diagnoses, to administer research grants, and to spur those with lupus to share their stories. Lupus Link Minnesota funds research at local institutions, including the University of Minnesota and Mayo Clinic. (For more information on Lupus Link Minnesota, visit https://lupuslinkmn.org).
Quality of life
Despite progress in improving understanding of the The cause(s) of SLE molecular and cellular underpinnings of SLE, and remain unknown. in the development of new treatments, SLE remains an incurable, chronic, and significant quality of life-degrading disorder in 2018. Moreover, SLE patients are subject to frequent, weeks- or monthslong flares of tissue-damaging disease activity. Flares often occur in spite of continuous application of standard therapies such as anti-malarials and corticosteroids. These facts Ongoing research form rationales for mounting a multi-disciplinary team-based approach to Current work by investigators at the University of Minnesota’s Center for optimize patient monitoring and disease management, and for the continued Autoimmune Disease Research (CADRe) focuses on mechanisms whereby search for novel biomarkers to help providers identify and head off SLE flares. abnormally activated immune cells contribute to tissue injury in SLE, and on In addition to rheumatology and primary care providers, optimal SLE defining the complex roles of recently described “risk” genes in pathogenesis. patient care frequently involves contributions from medical subspecialists, One Lupus Link Minnesota-supported study is examining the role of SLE prominently nephrologists and dermatologists. SLE-related patient symptoms risk genes in the immune response to candida, an organism that causes that frequently challenge these caregivers include persistent rashes, painful Systemic lupus erythematosus to page 384 oral ulcers, and mobility-limiting arthralgia, as well as depression and marked
Practice Opportunities throughout Greater Minnesota: Our nation faces an unprecedented number of individuals who having served their country now receive health care benefits through the VA system. We offer an opportunity for you to serve those who have served their country providing community based health care in modern facilities with access to world-leading research and research opportunities. We provide outstanding benefits with less stress and burnout than many large system policies create. We allow you to do what you do, best – care for patients.
Minneapolis VA Health Care System Metro based opportunities include: • Chief of General Internal Medicine • Chief of Nephrology • Cardiologist • Internal Medicine/Family Practice • Neurologist/Epileptologist • Psychiatrist • Tele-ICU (Las Vegas, NV)
Ely VA Clinic
Hibbing VA Clinic
Current opportunities include:
Current opportunities include:
Internal Medicine/Family Practice
Internal Medicine/Family Practice
US citizenship or proper work authorization required. Candidates should be BE/BC. Must have a valid medical license anywhere in US. Background check required. EEO Employer.
Possible Education Loan Repayment • Competitive Salary • Excellent Benefits • Professional Liability Insurance with Tail Coverage
For more information on current opportunities, contact: Yolanda Young: Yolanda.Young2@va.gov • 612-467-4964 One Veterans Drive, Minneapolis, MN 55417
JUNE 2018 MINNESOTA PHYSICIAN
A Place To Be Your Best.
Dr. Julie Benson, MN Academy Family Physician of the Year
Coming together to care for you.
Join our family of physicians POSITIONS AVAILABLE:
OB GYN & FAMILY MEDICINE – Full-scope practice available (ER, OB, C-Section, Hospitalist, Clinic) • Independent/growing system • Located in the heart of lakes country, Staples, MN • Critical access hospital with 5 primary clinics and a senior living facility • 15 family medicine physicians and 16 advanced practice clinicians • Competitive salary, benefits, and sign-on bonus available Contact Michael Paul at 218.894.8633, or email@example.com
Fairview Health Services is an award-winning, nonprofit health system, providing exceptional care across the full spectrum of health care services. Joined by HealthEast in June 2017, Fairview is one of the most comprehensive and geographically accessible systems in the state, serving the greater Twin Cities metro area and north-central Minnesota. 12 hospitals – including an academic medical center and long-term care hospital 56+ primary care clinics and 55+ specialty care clinics 30+ retail pharmacies and specialty pharmacies
Helping physicians communicate with physicians for over 30 years.
Call 1-800-842-6469 Email firstname.lastname@example.org Visit fairview.org or healtheast.org
Advertising in Minnesota Physician is, by far, the most cost-effective method of getting your message in front of the over 17,000 doctors licensed to practice in Minnesota. Among the many ways we can help your practice: • Recruit a new physician associate • Share new diagnostic and therapeutic advances • Develop and enhance referral networks
Fairview & HealthEast Physician Opportunities Cardiology (EP)
Family Medicine w/OB
IN MINNESOTA PHYSICIAN
TTY 612-672-7300 | EEO/AA Employer
MINNESOTA PHYSICIAN JUNE 2018
3Systemic lupus erythematosus from page 36
and urine have recently suggested that certain cytokine levels in patient serum and urine will have clinical utility.
opportunistic infections in immunosuppressed people, including SLE patients. Another locally supported study is testing the hypothesis that signaling by adenosine receptors can inhibit the crosstalk between T and B lymphocytes that results in high circulating levels of potentially tissue-injuring antibodies in SLE. In the past, blood markers of complement consumption, including serum levels of C3 and C4, as well as serum titers of auto-immune immunoglobulin specificities such as anti-dsDNA, have been utilized to gauge disease activity and to forecast oncoming flare. Unfortunately, these markers suffer from both poor sensitivity and specificity and are consistently useful in only a minority of SLE patients.
Several studies have found correlations between SLE disease features and/ or activity and serum levels of BLyS and APRIL, cytokine ligands for a signaling pathway important for promoting autoreactive B cell survival. Others found correlations between urine levels of the cytokine TWEAK (TNF-like weak inducer of apoptosis) and disease activity measures for lupus nephritis over time, according to Dr. Arriens. Ongoing investigations seek to confirm these findings More effective markers [may] soon be identified. and to better define the clinical scenarios in which novel SLE biomarkers are most useful.
Recent advances in “omics” methodologies, in which hundreds or thousands of analytes comprising genes, transcripts, or proteins can be probed simultaneously, hold promise that more effective markers will soon be identified. Work in the past five years by a number of groups, including at the University of Minnesota and Mayo Clinic, suggested that blood levels of genes induced by type I interferon (discussed above) will have improved capacity to help clinicians predict and head off disease flares. Moreover, Dr. C. Arriens, reviewing progress in biomarker development in the journal Rheumatology (April 2017), reports that proteomic investigations of serum
An incurable, chronic autoimmune condition that may cause permanent organ injury and even death, SLE remains a significant quality of life-degrading disorder. Ongoing research, including studies at the University of Minnesota and Mayo Clinic, hold the promise of improved diagnosis and treatment. Erik J. Peterson, MD, has strong interests in the molecular underpinnings of autoimmune diseases, including rheumatoid arthritis, lupus, and myositis. He practices general rheumatology and participates in resident and fellow teaching at the University of Minnesota’s Division of Rheumatic and Autoimmune Diseases, where he’s been on staff since July 2002.
Carris Health is the perfect match “I found the perfect match with Carris Health.” Dr. Cindy Smith, Co-CEO & President of Carris Health
Carris Health is a multi-specialty health network located in west central and southwest Minnesota. Carris Health is the perfect match for healthcare providers who are looking for an exceptional practice opportunity and a high quality of life. Current opportunities available for BE/ BC physicians in the following specialties: • Dermatology • ENT • Family Medicine • Gastroenterology • Geriatrician • Hospitalist
• Internal Medicine • Nephrology • Neurology • OB/GYN • Oncology • Orthopedic Surgery
• Pediatrics • Psychiatry • Psychology • Pulmonary/ Critical Care • Rheumatology • Urology
Loan repayment assistance available.
FOR MORE INFORMATION: Shana Zahrbock, Physician Recruitment | Shana.Zahrbock@carrishealth.com | (320) 231-6353 | acmc.com We are pleased to introduce Carris Health, a new entity launched in January to deliver high quality health care to West Central and Southwest Minnesota. Carris Health is a partnership between ACMC Health, Rice Memorial Hospital and CentraCare Health. This partnership allows us to reach beyond our individual capabilities to combine the talent and skills of all three organizations. Visit www.carrishealth.com for more information.
JUNE 2018 MINNESOTA PHYSICIAN
Family Medicine & Emergency Medicine Physicians • • • • •
Immediate Openings Casual weekend or evening shift coverage Set your own hours Competitive rates Paid Malpractice
St. Health Cloud VA Care System Brainerd | Montevideo | Alexandria
Opportunities for full-time and part-time staff are available in the following positions: • Physician (Internal Medicine/Family Practice) • Physician (Hospice & Palliative Care)
• Physician (Pain Clinic/Outpatient Primary Care) • Psychiatrist (Mental Health)
• Physician (Pulmonologist) Part-Time
763-682-5906 | 763-684-0243 email@example.com www.whitesellmedstaff.com
with a Mankato Clinic Career Established in 1916, physician-owned and led Mankato Clinic is 100 years strong and seeking Family Physicians for outpatient-only practices. Over 50% of our physicians are involved in leadership positions and make decisions for our group. Full-time is 32 patient contact hours and 4 hours of administrative time per week. Four-day work week available. Clinic hours are Monday-Friday, 8 a.m.-5 p.m. OB is optional. Call is telephone triage, 1:17, supported by a 24/7 Nurse Health Line. Market-competitive guaranteed starting salary, followed by RVU production pay plan. Benefits include 35 vacation / CME Days annually + six holidays, $6,600 annual CME business allowance and a generous profit-sharing 401(k) plan. We’re just over an hour south of the Mall of America and MSP International Airport. If you would like to learn more about building a Thriving practice, contact:
Dennis Davito Director of Provider Services 1230 East Main Street Mankato, MN 56001 507-389-8654 firstname.lastname@example.org
• Physician (IM/FP) Montevideo MN
US Citizenship required or candidates must have proper authorization to work in the U.S. Physician applicants should be BC/BE. Education Debt Reduction Program funding may be authorized for the health professional education that was required of the position. Possible recruitment bonus. EEO Employer. Competitive salary and benefits with recruitment/ relocation incentive and performance pay possible.
For more information:
Visit www.USAJobs.gov or contact Jane Blommel, STC.HR@VA.GOV Human Resources 4801 Veterans Drive, St. Cloud, MN 56303
Apply online at www.mankatoclinic.com MINNESOTA PHYSICIAN JUNE 2018
3Predesign in health care construction from page 21 design must include great flexibility for future changes to the way spaces are used. • Security is an increasingly important priority for all hospitals, so it is important to integrate security options and measures into each design. • Civic benefits are an especially important consideration for government-owned hospitals, and/or where the location of civic assets impact local populations in particular ways.
practice and specialty clinics, short- and long-term care facilities, nursing homes, recovery centers, and a myriad of others must also place great value on predesign during building and renovation projects. Each type of health care facility brings its own unique needs, requirements, and desires to both improve patient care and remain fiscally responsible.
Every building project must consider the future.
Once there is a solid view of the facility and its needs, and once these questions are answered, the predesign can serve the facility in completing a single project, or the information gathered could be used to develop a master plan and long-term strategy to meet the facility’s needs. Often, due to budget constraints, or in cases where an area of the facility is currently adequate but will become obsolete or in need of future repair, those items will be included in the master plan. Master plan timelines vary for each facility. Some span one year, others a decade.
If your organization is considering a building project, it’s important that you work with a skilled architect who can help you walk through the predesign process. There are numerous resources available to help you begin this process. Engan Associates Architects can provide information on beginning a building project or, more specifically, on the predesign phase. Richard P. Engan, AIA, CID, LEED AP, an architect
and partner with over 40 years of experience, is the founding partner of Engan Associates in Willmar. Specializing in the design of medical facilities, he is a LEED Accredited Professional and a certified interior designer.
Jason R. Grabinger is an administrative professional with Engan Associates in Willmar, specializing in content development and marketing. The newest
Health care menagerie
member of the Engan team, he previously founded and operated a content
There is a menagerie of health care facilities. Predesign is equally important for non-hospital facilities as well. Surgical centers, physical therapy centers, family
marketing firm in St. Cloud.
Change Lives Boynton Health is a national leader in college student health. We serve the University of Minnesota, delivering comprehensive health care services with a public health approach to campus well-being. Our patients are motivated and diverse undergraduate, graduate and international students, faculty and staff. On campus, you will have access to cultural and athletic events and a rich academic environment. Boynton is readily accessible by transit, biking and walking. With no evening, weekend or on-call hours, our physicians find exceptional work/life balance.
PHYSICIAN Boynton Health is seeking a full-time physician in Primary Care and Urgent Care Clinics. We have in-house mental health, pharmacy, physical therapy, lab, x-ray and other services to provide holistic care of your patients. This position offers a competitive salary, comprehensive benefits, CME opportunities and a generous retirement plan. Professional liability coverage is provided.
To learn more, contact Michele Senenfelder, Human Resources at 612-301-2166, email@example.com Apply online at http://www1.umn.edu/ohr/employment and search Keyword 324537. The University of Minnesota is an Equal Opportunity, Affirmative Action Educator and Employer.
410 Church Street SE, Minneapolis, MN 55455 612-625-8400 www.bhs.umn.edu
JUNE 2018 MINNESOTA PHYSICIAN
For more information, contact TSgt James Simpkins 402-292-1815 x102 firstname.lastname@example.org or visit airforce.com Â©2013 Paid for by the U.S. Air Force. All rights reserved.
MINNESOTA PHYSICIAN JUNE 2018
3Violence in the ED from page 19
devices, and an observation window are some of the items to consider in these spaces.
children’s play areas, calming lighting, comfortable furniture, and finishes that provide a feeling of welcome and security should be incorporated. Triage. Patients who have registered and gone through triage but are then sent back to the lobby to wait a second time may experience the stress of negative progression. This can lead to a feeling of discrimination or neglect, adding to an already tense situation. This can be avoided by designing post-triage waiting areas with distinct areas for fast-track, high- and low-acuity. These second-stage waiting areas, designed as alcoves, avoid the need for patients to return to a previous location.
According to OSHA, the single most important design element in reducing WPV is offering a system for communicating in an emergency. Physicians and nurses in danger need a way to signal for help, and the people receiving the signal should know how to respond. A variety of alarm systems exist, whether silent or audible, Physicians and nurses in danger stationary or mobile. Their design and use should be need a way to signal for help. well-coordinated with the architecture, operational policies, and training schedule.
Care zones. Isolation of staff within the care delivery space should be avoided, as this leaves them vulnerable. Staff areas should enable visibility within and between zones. Likewise, patient rooms should never be cut off from the nurse station’s line of sight. Floor plans that isolate nurses in decentralized workstations should be reconsidered. Behavioral health/observation rooms. Specialized rooms for behavioral health patients should be located away from other treatment spaces so as not to disturb other patients in the area, but also placed to remain visible to a central workstation. Impact-resistant laminate, locked cabinetry, locked roll-down walls, tamper-proof hardware, anti-ligature
JUNE 2018 MINNESOTA PHYSICIAN
If you do one thing
Some design solutions to WPV require an overhaul of the existing ED, but most don’t. An experienced architect can help determine which interventions are the most cost-effective for your situation, and should be consulted as part of any WPV prevention and response plan. Elizabeth Schulze, AIA, LEED AP BD+C, leads the health care design practice of Leo A Daly in Minneapolis. An architect registered in Minnesota and South Dakota, Schulze received her bachelor’s and master’s degrees from the University of Minnesota. She is passionate about using architecture to improve population and community health, and is an expert in sustainable building design and construction.
STAY FOCUSED AMONG THE DISTRACTIONS.
Minimize the things that get in the way of why you’re in healthcare to begin with. A focus on reducing lawsuits is just one way we do this. For more information or your nearest agent, contact us at 800.225.6168 or through coverys.com. M E D I C A L P R O F E S S I O N A L L I A B I L I T Y I N S U R A N C E A N A LY T I C S R I S K M A N A G E M E N T E D U C A T I O N
Insurance products issued by ProSelect® Insurance Company and Preferred Professional Insurance Company® MINNESOTA PHYSICIAN JUNE 2018
is for babies. Specialized maternal-fetal care for women As the only academically affiliated maternal-fetal specialists in the region, our experts collaborate with other University of Minnesota Health specialists to provide the highest level of care for women and their babies. Our program includes screening and treatment for pregnancy-related conditions and genetic consultations by board-certified experts to help patients prepare an individualized care plan.
Maternal-Fetal Medicine Center locations: Burnsville | Edina | Minneapolis 24-hour emergency referrals or consultations: 800-MFM-FOR-U (800-636-3678) Visit MHealth.org/MFM to learn more.
The University of Minnesota Health brand represents a collaboration between University of Minnesota Physicians and University of Minnesota Medical Center. ÂŠ 2018 University of Minnesota Physicians and University of Minnesota Medical Center