Minnesota Physician • June 2021

MINNESOTA

JUNE 2021

PHYSICIAN

THE INDEPENDENT MEDICAL BUSINESS JOURNAL

Volume XXXV, No. 02

The Future of Rural Healthcare Architecture Beyond the Building

BY TODD MEDD, AIA AND KRISTINE SALLEE, CID, LEED AP ID+C

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n 2021 the term “rural healthcare” lies in a politically correct universe somewhere between pariah and relic. Phrases like “outstate” or “Greater Minnesota” are now considered more appropriate for almost anywhere outside the Metro areas, and smaller communities are homes to top quality, cutting edge health care facilities. Perhaps the term “rural” evokes unintended comparison to Mayberry R.F.D., but in reality, 97% of today’s U.S. geography — nearly a quarter of the U.S. population — falls under rural healthcare delivery.

With the population spread out over a wide land area, the geography of rural America makes access to healthcare a prominent challenge.

Maternal and Infant Health Disparities Strategies for Reduction

BY RUTH RICHARDSON, JD AND ALICE MANN, MD, MPH

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n 2020, Minnesota leaders declared racism a public health crisis – including the Hennepin County Board, the Minnesota House of Representatives, the Minneapolis City Council and Mayor and the Olmsted County Board of Commissioners. The Minnesota House became the first legislature in the nation to pass a statewide declaration naming this crisis and created the House Select Committee on Racial Justice.

Maternal and Infant Health Disparities to page 104

To address the issue, we dissect four areas that can be improved with innovation in architectural design: population, place, professionals, and The Future of Rural Healthcare to page 144

Peter Schultz, MD, MPH Medical Director Nura Pain Clinics R. Scott Stayner, MD, PhD Medical Director Nura Surgery Centers David Schultz, MD Chief Executive Officer Nura Pain Clinics

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JUNE 2021 MINNESOTA PHYSICIAN

53RD SESSION

JUNE 2021

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Publishing November 2021

Volume XXXV, Number 02

COVER FEATURES Maternal and Infant Health Disparities Strategies for Reduction

By Ruth Richardson, JD and Alice Mann, MD, MPH

The Future of Rural Healthcare Architecture Beyond the Building

By Todd Medd, AIA and Kristine Sallee, CID, LEED AP ID+C

DEPARTMENTS CAPSULES .................................................................................. 4 INTERVIEW .................................................................................. 8 Fifty Years of Health Care Quality Innovation Jennifer P. Lundblad, PhD, MBA Stratis Health

HEALTH CARE ARCHITECTURE HONOR ROLL................................. 16

CLINICAL AND NON-CLINICAL CARE TEAMS Improving interoperability BACKGROUND AND OBJECTIVES: As health care costs constantly rise, containment strategies involve care teams. Many individuals are now part of every physician-patient encounter. Some are hands-on with the patient, some the patient never sees. New entities become part of care teams, offering services from chronic care management, to behavioral health screening, to care coordination, to coding, charting and much more. With goals of lowering costs, increasing reimbursement, and improving outcomes, clinics can customize teams to individual patient needs. Keeping up with this rapidly evolving landscape can exceed the capacity of many medical groups.

Our remote panel of diverse stakeholder perspectives will examine the diversity of care teams and how they interact. We will explore benefits that could result from improved coordination of these care teams. We will identify the barriers to this improved communication, such as incompatible EHRs and data privacy issues, and ways around them. We will provide examples of successful integration of clinical and non-clinical care teams and a road map for adopting and scaling these models for all elements of our health care delivery system.

sponsored by

JOIN THE DISCUSSION www.MPPUB.COM PUBLISHER

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Mike Starnes, mstarnes@mppub.com

ART DIRECTOR______________________________________________________ Scotty Town, stown@mppub.com Minnesota Physician is published once a month by Minnesota Physician Publishing, Inc. Our address is PO Box 6674, Minneapolis, MN 55406; email comments@mppub.com; phone 612.728.8600;. We welcome the submission of manuscripts and letters for possible publication. All views and opinions expressed by authors of published articles are solely those of the authors and do not necessarily represent or express the views of Minnesota Physician Publishing, Inc. or this publication. The contents herein are believed accurate but are not intended to replace medical, legal, tax, business, or other professional advice and counsel.

No part of the publication may be reprinted or reproduced without written permission of the publisher. Annual subscriptions (12 copies) are $48.00/ Individual copies are $5.00.

As we transition to a post-pandemic business world, health care will lead the way in terms of new policies, procedures and readiness. The Minnesota Health Care Roundtable has adjusted to these dynamics.

We now invite our readers to participate in this now remote conference process. If you have questions you would like to pose to the panel, or have topics you would like the panel to address, we welcome your input.

Please email: Comments@mppub.com and put “Roundtable Question” in the subject line.

MINNESOTA PHYSICIAN JUNE 2021

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Tri-County Health Care Breaks Ground on $72 Million Facility On May 21, members of Tri-County Health Care staff and several guests broke ground on a dynamic new construction project. With a tentative completion date of spring 2023 the new facility is located on the western edge of Wadena, a little less than two miles from the current hospital. “The recipe for this has been creativity and passion for the people involved, a lot of intelligence and wisdom, a fair amount of stress, some hand-wringing and sleepless nights,” said Joel Beiswenger, President & CEO of Tri-County Health Care.

John Poston, Minnesota District 9A State Representative noted “It’s so efficient and patient-centered; it’s going to be a big step up in health care for everybody in our region. It’s also going to be a big step up for jobs and be a good economic engine in

the area”. The new space will allow staff to serve a larger number of patients more efficiently as the current hospital and clinic have simply been outgrown. The new facility will feature standardized exam rooms in the clinic, hospital and outpatient service areas and a modernized birthing center with spacious, luxurious delivery rooms, including whirlpool baths, and a family-friendly environment. In addition, the surgical suites are much larger, expanding the types of procedures currently offered and accommodating the latest technology. The new facility brings a majority of patient care services under one roof and centralizes entry points to allow for better security and efficient navigation for patients, guests and employees. Lessons and design elements learned during the pandemic were applied to new strategies for infection control and disease spread mitigation. With an innovative architectural plan, leading-edge

technology and a visible location along Highway 10, the new facility will strengthen both Tri-County Health Care and its communities’ position within the region. This will help to attract and retain the best medical team possible and promote commercial development and partnerships while providing the best possible care. It is anticipated that the new facility will be a great economic driver with over 30 new projected jobs added after its completion.

BC/BS MN Expands Support to Independent Providers Blue Cross and Blue Shield of Minnesota recently announced investments in technology and practice support resources for four independent medical care organizations across the state, allowing new capabilities in optimizing the quality of care for patients and overall financial

management. Entira Family Clinics, Integrity Health Network, St. Luke’s Hospital and Winona Health are now connected to a web-based data analytics and care coordination platform from Stellar Health (Stellar), a health care technology company that provides insights into quality and cost of care measures while facilitating real-time financial rewards for appropriate care coordination practices. In 2020, Blue Cross announced a collaboration with Stellar and the Minnesota Healthcare Network – a group of 47 independent primary care clinics in Minnesota and Wisconsin – to accelerate the transition to value-based payment and provide financial resources for long-term stability. With this most recent expansion, more than 500 independent primary care providers across Minnesota are now participating in this value-based program. “Blue Cross recognizes the transition to a value-based care payment model

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can be especially challenging for independent providers,” said Karen Amezcua, senior director of provider partnerships at Blue Cross and Blue Shield of Minnesota. “That is why we’re committed to providing infrastructure and financial support to independent providers participating in value-based care throughout the state, with the goal of ensuring high-quality care at a lower overall cost for our members.” Additional compensation will be provided to health care practitioners and their staff upon completion of appropriate care coordination activities. “Managing complex health conditions is critical to delivering optimal health outcomes at a lower cost for St. Luke’s patients,” said Kim Terhaar, vice president of Ambulatory Care at St. Luke’s Hospital. “This innovative collaboration with Blue Cross enables us to more seamlessly transition to a value-based care delivery model.”

“We are honored to assist Blue Cross in their effort to help independent providers find success in value-based care,” said Michael Meng, chief executive officer at Stellar Health. “By rewarding each value-based action completed, Stellar and Blue Cross are helping to create economic stability for independent providers as they move away from an unsustainable fee-for-service model.”

company makes ordering a house visit as easy as texting your friend or requesting an Uber and eliminates waiting room time. In addition to a wide range of telehealth support and follow-up options, prescription delivery services are also available. Kavira believes that by removing the barriers associated with accessing care, their patients will increase utilization of care, making them healthier in the long run, and eventually lowering their overall cost of care. “I grew up in a family with quadruplet younger siblings that required constant attention from the healthcare system, so from a very young age I had internalized the difficulty – inconvenience, poor patient experience, long waits, high costs – associated with seeking care,” said CEO and founder Andrew Headrick. The company employs board-certified advanced care practitioners and can diagnose and treat an extensive range of conditions, however not every patient or condition is within their scope of practice. These qualifications can be made quickly, for example Kavira is not a good fit for Medicare recipients, newborns or those requiring specialist care. Services are currently available only in the Twin Cities Metro area. Initial response has been strong with significant opportunity to expand the range and scope of services provided.

Kavira Brings Back the House Call

St. Francis Expands Mental Health Services

Eight weeks ago, Kavira, a Minneapolis-based health care start up began offering primary care and urgent care house call visits. With services for both individuals and small employers the company offers a range of access from one time to subscription options. Their simple fee structure ($35/mo for ongoing care to $200 for a single in home visit) eliminates problems around the typical non-existent price transparency in health care as well as drive time to and from a clinic or urgent care center. The

In late May St. Francis Regional Medical Center broke ground on a $5 million mental health emergency department expansion. The plan includes adding six new rooms designed specifically for patients experiencing mental health emergencies by providing them extended time to stabilize. The expansion will allow the ER staff to respond to and care for individuals suffering from mental health emergencies. The emergency department will incur minimal disruption during construction and

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MINNESOTA PHYSICIAN JUNE 2021

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remain fully operational. The new mental health emergency space is anticipated to open in late 2021. “St. Francis is committed to ensuring emergency mental health care to our growing community and offering the safest environment for those patients at their most vulnerable time,” St. Francis President Amy Jerdee said.

“We have carefully tailored our expansion plans to meet our objectives, while balancing the needs of the growing population with our commitment to financial responsibility.”

The Shakopee Mdewakanton Sioux Community donated $1 million to the expansion — the largest capital donation in the hospital’s history.

The rest of the project will be funded from resources previously set aside for reinvestment in the hospital, as well as from a campaign to help fundraise for the project. “Our community is experiencing unprecedented growth and our current mental health facilities cannot keep up with the demand

in a way that honors our commitment to patients and their families,” said Christine Delmonico, an emergency physician at St. Francis. “Access to state-of-the-art emergency mental health care directly contributes to the health and safety of our growing community, while keeping our staff and patients safe, and providing a healing environment for our patients experiencing mental health emergencies.”

Mayo Announces Breakthrough in Early Cancer Detection Earlier this month the Mayo Clinic released news of a groundbreaking multi-cancer early cancer detection (MCED) test called Galleri™. The new test can detect more than 50 types of cancers through a simple blood draw and complements U.S. guideline-recommended cancer screenings. One of the test developers, Oncologist and co-director

of the Mayo Genomics in Action Program Minetta Liu, M.D., said “Today, many cancers are found too late, leading to poor outcomes. The ability to detect cancer early is critical to successful treatment.” Researchers used the Galleri test in the Circulating Cell-free Genome Atlas (CCGA) Study, a prospective, observational, longitudinal study designed to characterize the landscape of genomic cancer signals in the blood of people with and without cancer. In the study, the Galleri test demonstrated the ability to detect more than 50 types of cancers — over 45 of which have no recommended screening tests today — with a false-positive rate of less than 1% . When a cancer signal is detected, the Galleri test can identify where in the body the cancer is located with high accuracy — a critical component to direct diagnostic next steps and care. Recent results involving the return of Galleri test data to providers to communicate to

participants, were presented at the 2021 American Society of Clinical Oncology Annual Meeting. They demonstrated Galleri’s performance in clinical settings was consistent with findings from previous observational studies, underscoring the potential real-world ability of Galleri. Dr. Josh Ocman, the Chief Medical Officer for GRAIL, a Menlo Park-based biotech company involved with early cancer detection said “We are grateful to Mayo Clinic for its dedication to advancing new technologies for early cancer detection and for playing a pivotal role in the development of Galleri. A simple blood test capable of detecting more than 50 cancers is a ground-breaking advancement and could have a tremendous human and economic benefit.” Cancer is projected to become the leading cause of death in the U.S. this year. Currently recommended screening tests only cover five cancer types and screen for a single type at a time. There are no

WE’RE EXPANDING WAYS TO HELP YOUR PATIENTS Announcing new medical conditions accepted for Minnesota’s Medical Cannabis Program: • Sickle cell disease • Chronic motor or vocal tic disorder Patients with these conditions can be certified starting July 1.

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recommended early detection screening tests for cancers which account for well over half of all cancer deaths.

ICSI Announces Cease of Operations Last week, Claire Neely, MD, the President and CEO of the Institute for Clinical Systems Improvement, announced that the organization would cease operation at the end of 2021. Originally founded in 1993 with a mission to create evidence-based guidelines that would help physicians improve their practice of medicine, the nonprofit collaborative went through a series of expansions and redefinitions that all centered around higher quality health care. As the organization gravitated to a membership based model, Dr. Nealy cited the struggles these kinds of organizations have had in recent years as a contributing factor to the decision.

Since its inception the organization has been lead by several individuals with outstanding vision and commitment as they became a vital part of Minnesota’s collaborative healthcare community. The contributions ICSI has made to evidence-based clinical care, quality improvement and collective action in the state and region will remain as benchmarks for many years to come. Recent areas of focus have included efforts in opioid prescribing quality improvement, suicide prevention and intervention, supporting the workforce, telehealth, and a collective effort on racial equity in healthcare. While some of ICSI initiatives may wrap up in 2021, many of the important collaborations, including ones that have arisen during the pandemic, will continue in modified form while others will be transitioned to different organizations. “We appreciate everyone who has been part of ICSI in leading health care improvements in our state and our

region. My ICSI colleagues I share a tremendous sense of gratitude for the collaborative spirit that has accomplished so much towards solving our toughest healthcare challenges” said Dr. Neely. More details for a transition plan will be released at the end of the month.

New Partnership Improves Health Care for Medicaid Enrollees Accra, Minnesota’s largest homecare provider, and Minnesota Community Care, the largest federally qualified health center in the state, are partnering to improve health care access for Minnesota Medicaid enrollees. Both organizations primarily serve people with barriers to care, including children and adults with disabilities and older adults. The partnership grew from the opportunity to share resources and expertise that would improve their clients’ health care outcomes. Using homecare-assisted telehealth appointments and in-home care management provided by Accra, Minnesota Community Care’s physicians will have more information about the full daily experience of their patients, and patients will get help following physicians’ orders at home. Accra nurses bring technology into the home and gather appropriate clinical data prior to connecting to Minnesota Community Care physicians and clinical care providers, then homecare providers help clients follow through with their medical plan. By working together, doctors and in-home caregivers are able to identify other factors that impact overall health, such as adequate nutrition, drug adherence or isolation.

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MINNESOTA PHYSICIAN JUNE 2021

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INTERVIEW

Fifty Years of Health Care Quality Innovation Jennifer P. Lundblad, PhD, MBA Stratis Health Please tell us how Stratis Health got started.

access to hospital care in rural communities.

We continue to work in partnership with the Minnesota Office of Rural Health and Primary Care to provide training and technical assistance in support of our state’s now 79 rural critical access hospitals to ensure access to high-quality health care that is aligned with community needs.

Stratis Health was established as the Foundation for Health Care Evaluation in 1971 by a group of Minnesota physician leaders. We are proud of our commitment to improving the health and care of seniors through our service as a federally designated Medicare quality improvement organization — the most longstanding of our programs. We changed our name to Stratis Health in 1997, when the Health Outcomes Institute merged into our organization. Our commitment to improving health and health care continues to grow with each passing year, and we have expanded far beyond our Medicare quality improvement roles to be a national leader in health improvement.

Your work with Medicare has been a drove those early projects and how did they develop?

Our work in the early decades focused on quality assurance. As the field of health care quality evolved to embrace quality improvement and patient safety science and tools, so did Stratis Health. In our early days, the organization served as a Professional Standards Review Organization for Medicare, then part of the Health Care Financing Administration (HCFA). In the early ‘90s, HCFA introduced the Health Care Quality Improvement Program, adding a program with hospitals and physicians to improve the quality of providing care, in addition to the quality assurance case review role we played. As part of our Medicare improvement work in the 1990s and 2000s, we led projects which were laser focused on the conditions and needs of seniors – from better care for chronic diseases such as diabetes and heart failure, to improving how hospitals addressed surgical care and antibiotic stewardship, to building capacity in long-term care in areas such as pain management and infection control. This early improvement work paved the way to the Quality Innovation Network focus of today’s Medicare quality programs, which we lead in Minnesota, Wisconsin, and Michigan as part of Superior Health Quality Alliance.

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To“...” work in health improvement, it’s important to be an optimist.

“...”

foundational part of Stratis Health. What

Today Stratis Health is guided by what you call the Transformation Framework. What can you tell us about this?

The Stratis Health Transformation Framework depicts the foundations necessary for organizations to improve and sustain change in health care and the actions needed and desired between health care and the community. Core to the framework is addressing health equity and social determinants to achieve better care, better health, and lower costs.

Stratis Health has become very active in rural health initiatives. Please tell us about some of this work.

Rural health improvement has been an organizational priority for more than 20 years and is a large and growing part of the improvement portfolio for Stratis Health. Early efforts began in 1999 as the first of Minnesota’s hospitals transitioned to what was a new hospital designation at the time, the Critical Access Hospital (CAH) program, intended to preserve the safety net of

That early work in Minnesota established Stratis Health as rural and CAH quality experts and has evolved into national leadership roles in rural health improvement for Stratis Health. Since 2015, we have served as the Rural Quality Improvement Technical Assistance (RQITA) program lead for the Federal Office of Rural Health Policy (FORHP), helping the 1,300+ CAHs and rural clinics across the country better measure and improve the quality of care they deliver. Since 2012, Our Rural Health Value initiative, in partnership with the University of Iowa, has leveraged our extensive analytic and technical assistance capacity to understand how evolving health care delivery and financing systems affect rural communities and clinical and nonclinical health care professionals and actions needed to create and sustain high-performance rural health systems. In all our rural health work, we leverage national partnerships with organizations and people dedicated to improving rural health — a real asset for rural health organizations with limited resources.

In addition to these federally sponsored roles, our Rural Community-based Palliative Care initiative, which has been funded by health plans and private foundations, helps develop skills and capacity in rural communities to better deliver care and support for those with serious illness. We developed a groundbreaking model more than a decade ago to increase access to palliative care services in rural communities by using a customized community-capacity development approach.

Stratis Health recently wrapped up its latest threeyear project supporting the development of rural community-based palliative care teams and service across three states and building foundational resources, including developing an implementation toolkit designed to improve health and reduce disparities in access and services

Please tell us about the Partnership to Advance Tribal Health.

Funded by the Centers for Medicare & Medicaid Services, the Partnership to Advance Tribal Health (PATH) is a strategic partnership of organizations committed to improving health care for American Indians. The work focuses on supporting the 24 Indian Health Services (IHS) hospitals across the country in continuous improvement in the quality of care. The American Indian and Alaska Native people have long experienced lower health status in comparison to other Americans, the cause of which is often rooted in economic adversity, poor social conditions, and historical trauma. Stratis Health is part of a team building trusted relationships with IHS hospitals across the country to support continuous improvement by implementing best practices and providing performance improvement training and coaching.

Another more recent area of focus involves health care disparities. What does some of

health equity and reducing health disparities, as guided by our Transformation Framework. We’ve discussed PATH and our rural health initiatives, but Stratis Health experts work on many projects designed to strengthen partnerships between health care and community organizations, reduce inequities, and harness data to uncover services or capacity that may be missing. For example, the collaborative Health Plan Performance Improvement Projects (PIPS) in Minnesota cover many health topics identified as priorities for improvement including preventive care, chronic illness management, and transitions in care, and currently focus on reducing disparities in maternal health and in diabetes. Culture Care Connection, developed in partnership with UCare, is an online learning and resource center to support clinical and non-clinical health professionals with tools and resources to build awareness skills and encourage action to help them be responsive to and supportive of the diverse patients and communities they serve.

improvement work pivoted to address the extreme challenges presented by the pandemic. We have been continuously working with our funders to best use our programs, resources, and relationships in redirected ways to support health care organizations in addressing COVID-19. Deep fractures in the US health care system, including a lack of coordination between health care and public health, became impossible to ignore with the pandemic and the fallout due to the murder of George Floyd co-occurring. The re-awakening about health disparities, structural racism, and financial challenges put extraordinary pressure on all stakeholders. Stratis Health is comprised of experienced, trusted experts in developing and guiding health improvement and safety initiatives across the continuum of care that result in better health and care for all people and communities. We have been further galvanized to meet the monumental challenges posed by COVID19 and social unrest and to do all we can to help stabilize our fragmented and inequitable health care system for the long term.

What are some of the ways Stratis Health has

this work entail?

Addressing social determinants of health is built right into our workflow as a key strategy to improve

worked with issues related to COVID-19?

Since April 2020, Stratis Health’s quality

Fifty Years of Health Care Quality Innovation to page 304

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3Maternal and Infant Health Disparities from cover The committee’s first order of business was a focus on the persistent and unacceptable racial disparities in maternal and infant mortality and morbidity.

The data is disturbing The United States has the highest maternal and infant mortality rate among comparable countries. A deeper look at the disturbing data uncovers a preventable public health crisis with profound racial disparities.

Black and Indigenous infants are twice as likely to die before their first birthday than White infants. The disparity between infant mortality rates for Black and White babies today is larger than the gap experienced under chattel slavery. However, when Black newborns are cared for by Black physicians, they are less likely to die in hospital settings and the excess mortality rate is cut almost in half.

Nationally, U.S.-born Black women have the worst maternal mortality and morbidity outcomes of any racial group; they are 3-4 times more likely to experience a pregnancy-related death than White women. Even when controlling for familial status, education, general nutrition, overall health, substance use disorder status, income, insurance and housing status, these stark disparities remain. The heartbreaking reality is that Black women are more likely to experience a preventable maternal death. The fact that 60 percent of the deaths are estimated to be preventable means that we can and must do better.

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dismantling racism and bias in our medical and behavioral health systems.

We also understand that the complexities of the crisis require communitybased responses and not only addressing the stigma associated with substance use disorders and mental illness but also recognizing the inequities and inequalities that persist across the behavioral health system.

Seen and not heard The recent near-death experience of tennis star Serena Williams drew muchneeded attention to the medical disparities Black women have experienced for decades. Williams made national news recounting her ordeal, which began when she found herself gasping for air after an emergency c-section. She had a history of blood clots and pulmonary embolism, but had stopped her regimen of anticoagulants in preparation for the surgery. Williams immediately recognized the symptoms of another embolism. She walked out of her hospital room to find the nearest nurse, and between gasps told her that she needed a CT scan and IV heparin right away. The nurse disregarded her request for medical attention, believing that she was confused from her medications.

Eventually a doctor performed an ultrasound of her legs, which revealed nothing. When doctors finally complied with her repeated requests for a CT scan, they discovered several blood clots in her lungs and immediately began treatment. The delay in addressing her embolism and intense coughing led to a rip in her c-section wound. What followed was an emergency surgery, the discovery of an additional hematoma and a 6-day medical crisis. When Williams finally returned home, she needed six weeks of bed rest.

For every Serena Williams, there are countless stories of Black women that you do not hear about, the “hidden figures.” Women like Amber Rose Isaac, who pleaded for help from her maternal healthcare providers before her death. On April 17, 2020, Isaac tweeted that she should write a “tell all” about the incompetence of her medical team. Less than four days later, she was pronounced dead after a c-section that went wrong. Because her partner was not allowed into the hospital during the pandemic, she died alone. Isaac suffered from a treatable complication called HELLP syndrome. This condition typically proves fatal for only a small number of women who go without treatment. Her surviving family members describe a pregnancy riddled with neglect by rude and unprofessional staff that ignored her cries for help even as she repeatedly reached out to them in her last weeks.

Shalon Irving, a Lieutenant Commander in the U.S. Public Health Commissioned Corps and an epidemiologist at the Centers for Disease Control who had dedicated her career to eliminating health inequities, died 3 weeks after childbirth from complications of high blood pressure. After discharge, Irving had made visit after visit to her primary care providers because she knew something was wrong. First for a painful hematoma at her c-section incision site, then for spiking blood pressure, headaches, bladder issues, blurred vision, swelling legs and rapid weight gain. Doctors repeatedly assured her that the symptoms were normal. Hours after her last medical appointment, she collapsed. One week later she was removed from life support.

Twenty-six-year-old Sha-Asia Washington died during childbirth last July. Washington reported difficulty breathing shortly after receiving epidural anesthesia and other sedatives. Her cries for help went unheard, and providers did not appropriately administer oxygen. Washington went into cardiac arrest while doctors delivered her daughter Khloe via c-section. She Maternal and Infant Health Disparities to page 124

Patients with regenerative medicine questions?

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3Maternal and Infant Health Disparities from page 12

A long, foundational history of racism in the healthcare system

was pronounced dead after doctors spent 45 minutes trying to revive her.

The disparities in maternal infant health in Minnesota and across the nation are the predictable outcomes of a healthcare system working just the way About 700 women die of pregnancy-related complications each year in it was designed to work. There is a dark history associated with the origins the U.S., and the largest share are Black women. What these four stories – of OB-GYN care in this country, and the legacy of along with a growing body of academic research – tell that mistreatment continues down to the present day. us is that there is currently no protective factor against The “father of modern gynecology,” J. Marion Sims, structural racism in the medical field. Advanced contributed revolutionary tools and techniques to the education, good nutrition, overall good health, stable medical field. Many of Sims’ discoveries were made housing, access to prenatal care, great personal wealth Black and Indigenous infants are through horrific, painful experimentation on enslaved – none of it changes the risk for adverse outcomes if twice as likely to die before their Black women without the use of anesthesia. Today you are Black. first birthday than White infants. these women are unknown and unnamed except There is something deeply wrong with a healthcare for Anarcha, Betsey, and Lucy. Anarcha Westcott system that fails to value Black women’s lives and voices endured at least 30 procedures in the last 1800s. Sims’ equally to White women. The common thread in this decision not to use anesthesia on enslaved women was deadly epidemic is a Black woman expressing concern, based in the racist belief that Black people do not and her clinicians either disbelieving or delaying feel pain in the same way as White people. Anarcha, response. Not only is there a troubling pattern of Black Betsey, Lucy and the other unnamed enslaved women were not extended the women’s birthing concerns being dismissed, but traumatic birthing experiences same care, treatment or anesthesia of Sims’ White female patients. are so common that one-quarter of Black women report disrespect and abuse These misguided beliefs and misconceptions about how Black people from medical professionals in the hospital. At Wayside Recovery Center, we experience pain persist into the present day. Black patients receive less have heard too many stories of such mistreatment and the traumatic birthing pain medication than White patients across age ranges and conditions. experiences that have resulted in patients leaving the hospital early at great risk Disturbing beliefs that Black people’s nerve endings are less sensitive or to escape such treatment. that their skin is thicker is not a relic of the past. They are notions still We have the ability to change that reality. held by some medical students, residents, and doctors today. The abuse of enslaved bodies as medical test subjects is just one example of a historical legacy of medical apartheid that also includes the atrocities of the Tuskegee Experiment and the exploitation of Henrietta Lacks. A long history of medical atrocities towards Black and Brown people in America contributes to the lingering distrust of a healthcare system that has not consistently recognized the humanity and value of Black lives. But it is important to note that our healthcare system also has a deeply embedded distrust of the Black community as well. That distrust becomes clear with the stark disparities in maternal healthcare where the voices of Black women are being ignored and dismissed with deadly consequences.

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A Path Forward There is a pathway forward to address the maternal and infant health crisis, and it is possible to reduce these unacceptable disparities.

First, we must name the problem to address the issue. The healthcare field must acknowledge the roles that racism and implicit bias have in creating these disparities. Importantly, it is not race itself but systemic racism that acts as a social determinant of health and the primary driver of maternal and infant health inequalities. The healthcare field and its institutions must commit to becoming anti-racist, and can begin doing so by implementing mandatory, ongoing anti-racism and implicit bias trainings.

Wayside Recovery Center has launched its own educational series open to colleagues in the healthcare fields, to shine a bright light on maternal and infant health disparities. It will launch on June 29, 2021 with a talk by renowned family physician and epidemiologist Camara Phyllis Jones, MD, MPH, PhD, on Addressing Racism as a Public Health Crisis (waysiderecovery.org/camarajones).

We also know that representation in the medical field leads to better outcomes for all patients. The call for increased racial diversity among practitioners is not just about diversity for diversity’s sake. Rather, the data is clear that it saves lives. Achieving racial diversity in medicine starts further upstream with ensuring that students at all levels including in medical school have access to racially diverse teachers. The fact is that all students do better when they have access to Black, Indigenous, and other teachers of color.

systemically pushed them out of the field. Doulas currently struggle to earn a living wage in Minnesota and around the country. Creating sustainable pathways towards midwifery and doula care is key. Wayside Recover Center has integrated doulas into our care team to provide culturally appropriate emotional, educational and physical support to our clients.

The Black maternal and infant health crisis in our Minnesota and the nation is both disgraceful and preventable. And while this article sets out some important first steps to take, it is important to Maternal and Infant Mortality Review Committees highlight that there is no single policy initiative that are another important standard to identify, review and It is possible to reduce these will fix this public health crisis. Instead, we need a analyze deaths, disseminate findings and act on results. unacceptable disparities. multifaceted approach that reflects the complexity of Historically these review committees have been limited the crisis. Eliminating racial disparities in maternal to medical practitioners but expanding membership to and infant mortality and morbidity cannot be done include other professionals and partners is critical. In without addressing inequality and acknowledging fact, it is important that the voices of Black women our systems and structures were built with a and those with lived experience are represented and foundation of racial animus. But there is a growing that we ensure that those closest to the pain of these movement demanding change, and there is a hope issues have their voices heard as we work to reduce and that commitment will grow in the health care field to address this preventable eliminate disparities. Committees could be expanded to also include findings crisis. The lives of Black mothers and infants depend on it. of morbidity events, which are much more common than mortalities, using the Center for Disease Control Framework. Addressing morbidities would provide the opportunity for more significant prevention impact.

Ruth Richardson, JD, is Chief Executive Officer of Wayside Recovery Center.

There is important knowledge held beyond the traditional medical community as well. Black midwives have played a vital role for centuries in improving care and outcomes in our country. Modern policy concerns have

Alice Mann, MD, MPH, is Primary Care Medical Services Director at Wayside Recovery Center.

Do you have patients with trouble using their phone due to a hearing loss, speech or physical disability?

Contact the Telephone Equipment Distribution Program for easier ways to use the phone.

Phone: 800-657-3663 Email: dhs.dhhsd@state.mn.us Website: mn.gov/deaf-hard-of-hearing 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.

MINNESOTA PHYSICIAN JUNE 2021

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3The Future of Rural Healthcare from cover

health. Rural residents are less likely to participate in their healthcare system due to the perceived “neighbor” stigma. To create a new perception, we need to start with a well-planned design that can guide the patient’s journey more discreetly, from parking, to check-in, and waiting area. These areas can be reconfigured for less patient-to-patient visuals and heightened acoustic privacy.

pathways. With special consideration of facility design needs and community-based research, we can all work to transform the term “rural healthcare” to be perceived in a more positive light. With efficient pre-planning and collaborated design, architecture firms have the tools to execute solutions to more efficiently accommodate traveling patients, assist in Architects and designers have workforce retention, pinpoint closer-proximity a growing responsibility in access areas, and address privacy and remote care.

In some cases, virtual or kiosk check-in stations, along with patient self-rooming, have been useful in maximizing privacy and patient distance. In Moorhead, Minnesota’s Sanford Clinic, JLG Architects designed for the option of addressing healthcare delivery. both a patient concierge, as well as an electronic Population kiosk which assigns patients a Real-Time Locating Chronic health conditions are one of the most System tag for self-rooming. The staff is available influential determinants of health status, and to direct the patient to their exam room, and rural populations tend to see a higher incidence of intuitive wayfinding is used within the building’s these risk factors. Obesity, heart disease, diabetes, interior design through color-coded bulkheads and carpet tiles. In addition, and addiction, are more common without access to regular, individualized each exam room is equipped with a scale and blood pressure monitoring healthcare. It is not surprising that chronic health conditions are more common to take patient vitals in the privacy of their exam room. This is simply a in rural areas. The culture behind a community also heavily impacts the health collaborative, onstage-offstage care delivery model that makes clinic visits of its people. Patients in rural communities are 1.7 times more likely to avoid more efficient for the providers and less threatening for the patient. healthcare visits than their urban counterparts. Rural culture is derived from generations of “self-care” — believing themselves to be “more hearty”.

Privacy is major challenge in avoidance of healthcare as many rural patients are all too familiar with the doctors, nurses, and other patients in the healthcare setting. This is most commonly seen in the area of mental

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Sound insulation is also necessary in partitions around consultation rooms and telemental health space to prevent confidential conversations from traveling beyond the room. In a scenario that relies on common areas with open workstations, it’s crucial to designate private clinical office space

as well. Acoustically-sound consultation rooms or conference rooms can be used to meet this need.

Professional

but even more so in healthcare. In high-stress environments, it’s important that design incorporates natural light, respite spaces, quiet meditation rooms, larger outdoor spaces, and access to walking paths.

Design firms can collaboratively work to include a wide range of calming Among rural America’s challenges, the greatest is access to healthcare staff. work areas such as “huddle” spaces for informal The U.S. Department of Health and Human team collaboration, as well quiet workspaces that Services uses a metric and tool set to address access include acoustic detailing and technology that to medical, dental and mental health services supports auditory privacy. An effective design called Health Professional Shortage Area (HPSA). also integrates a modular planning approach that Patients in rural communities According to the American Hospital Association, can support future rearrangement and changes in are 1.7 times more likely to two-thirds of the nation’s HPSAs are located avoid healthcare visits than staffing and workflow. within rural areas. Rural healthcare systems face their urban counterparts. two issues related to staffing: not enough money Technology limitations in rural healthcare to bring on more staff, and not enough staff settings is another area to be addressed. Advancing interested in working for their systems. Healthcare instrumentation and software can be pivotal in is already following a trend of ultra-specialization recruiting and retaining existing staff, while helping by providers. This has resulted in fewer general reduce automated, day-to-day tasks. Additionally, practitioners, and a heightened expectation of doctor specialization by post-lockdown, we look at empty office spaces from departments that have patients. To maintain health in rural populations and workforce will require been successful working remotely. These office spaces can be effectively new and emerging partnerships. These will include more involvement and redesigned as virtual telehealth offices or private consultation rooms. investment by community city councils and local industry.

To address long-term employee retention, we consider post-pandemic stress levels in the wake of staff shortages, paying close attention to the toll of losing fellow co-workers and patients. This is an important catalyst in the conversation of why many healthcare environments need modernizing. Prioritizing staff well-being is a goal we are seeing across the board in architectural design,

Place

Rural populations often require travel for specialized healthcare services, and, as a result, are looking for a one-stop-shop approach when they arrive.

The Future of Rural Healthcare to page 264

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HEALTH CARE ARCHITECTURE

Mayo Clinic Health System Mankato Hospital Type of facility: Surgical Services Renovation and Expansion Location: Mankato, MN Ownership organization: Mayo Clinic Health System Architect/Interior design: Perkins & Will Engineer: IMEG Corp.

Contractor: The Boldt Company Completion date: February 2020 Total cost: N/A Square feet: 25,000 addition, 60,000 renovation

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he project centers on providing 14 new, right-sized, state of the art operating rooms. The surgical prep and recovery area expanded to accommodate 42 private, universal rooms for added flexibility. A vertical expansion above the Cancer Center houses the updated Gastroenterology Department, including 15 private prep and recovery rooms, 4 endoscopy procedure rooms and a shelled 5th procedure room for future expansion. The

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renovated department provides light-filled corridors and allows views to nature for patients and staff. A dynamic new two-story lobby links the public experience to nature while integrating daylight deep into the interior. Connecting the existing buildings simplified wayfinding across a complex existing network and provided a new space for public gathering, respite, and wellness including a café on the first floor and waiting spaces on the first and second floors.

For the past 33 years Minnesota Physician’s Health Care Architecture Honor Roll has recognized outstanding achievement in new facilities design. Despite every element of creating new environments for health care delivery experiencing COVIDrelated setbacks, a surprising number of exemplary new facilities were completed last year. The projects featured in 2021 will serve patients of all ages and health status at sites throughout the state. Our thanks to all those who participated in this year’s Honor Roll.

Winkley Orthotics & Prosthetics Type of facility: Clinic Location: Golden Valley, MN Ownership organization: Winkley Orthotics & Prosthetics Architect/interior design: BDH Engineer: Gilbert Mechanical Contractor: Timco Construction Completion date: July 2020 Total cost: $1,098,331 Square feet: 12,225

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enovation of main clinic with all functions utilized by patients relocated to the front of the clinic to improve convenience and circulation. The remodeled layout decreased the distance from the building entrance to the walking gym by 50%, and the square footage of the walking gym more than doubled, expanding the room for movement and elevating comfort.

Glass demountable walls allow energy and light to permeate throughout the space. With

enhanced patient navigation, the centralized design strengthens collaboration and efficiency among staff. The primarily neutral finishes and light wood tones permit Winkley’s signature teal to stand out. The prominent history wall highlights the company’s 130-year evolution by way of modernizing historic newspaper clippings, memorable photos, and original hand-drawn sketches.

MINNESOTA PHYSICIAN JUNE 2021

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HEALTH CARE ARCHITECTURE

VitreoRetinal Surgery Type of facility: Eye Care Clinic and Surgery Center Location: Edina, MN Ownership organization: VitreoRetinal Surgeons Architect/interior design: BDH Engineer: N/A Contractor: Greiner Construction Completion date: June 2020 Total cost: $1,310,663 Square feet: 15,000

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erving as a regional clinic and the company’s clinical research headquarters, the new environment was designed for efficient research practices and as a comforting place for patients. Entering VRS you are welcomed into an inviting lobby with large windows that create a calming effect full of natural light and beautiful views of Centennial Lakes Park. From the reception area, the efficient layout seamlessly guides patients to the clinical

areas. Offices dedicated for research and business operations are positioned to provide substantial amounts of natural light and amazing views all day long. The efficient layout reduces travel time for staff and provides easy access to exam rooms, which allows the practitioners to complete patient visits in a more productive manner.

The combination of the efficient flow, biophilic design, and prominent wayfinding elements contribute to a positive patient experience.

A Human-Centered Approach to Behavioral Health Promoting a caring and healing environment through the power of relationships from staff, patients, and their families.

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JUNE 2021 MINNESOTA PHYSICIAN

HONOR ROLL 2021

Essentia Health - Park Rapids Clinic Type of facility: Ambulatory Care Center Location: Park Rapids, MN Ownership organization: Essentia Health Architect/Interior design: EAPC Architects Engineers Engineer: EAPC Architects Engineers Contractor: Construction Engineers Completion date: 2020 Total cost: $7,107,390 Square feet: 32,969

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epurposing ‘Big-Box’ retail to an Ambulatory Care Center, this innovative renovation will serve the local community well into the future. Patients may be seen by multiple healthcare providers in one setting and one visit, ranging from their primary care physician to a phlebotomist, radiologist, pharmacist and physical therapist. The clinical module is designed as an on-stage/off-stage model, allowing more communication and team interaction. Collaborative work rooms replace

private offices for each care team. The waiting area features digital check-in and flexible social distance seating. Exam rooms with soundproof sliding doors are 30% larger than standard to accommodate families and care teams. The Facility includes two new general radiographic rooms and an MRI exam room. Dual entries in exam rooms and corridors dedicated to staff and patients address issues in treating infectious disease.

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HEALTH CARE ARCHITECTURE

Minnesota Drive Medical Campus Type of facility: Medical Building featuring ambulatory surgery center with physical therapy Location: Edina, MN Ownership organization: Frauenshuh, Inc & Twin Cities Orthopedics, P.A. Architect/Interior design: Sperides Reiners Architects, Inc. Engineer: BKBM Contractor: RJM Completion date: September 2018 Total cost: $29,000,000 Square feet: 70,1097

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eaturing an ambulatory surgery center, a two-story ‘field house’ space for physical therapy activities including basketball, weights, dance, etc, two Golftec golf simulator rooms for analysis and instruction, and medicaloffice space. Development required bringing utilities down public roadways (including water service all the way from Pentagon Park), installing 990 pilings to an average depth of approximately 100’, a kinetic test of the piling strength which

was the first completed in Minnesota in the last 10 years. The creativity in developing on this formerly undevelopable site and also obtaining approvals for an additional 10-story 180,000 sf building demonstrates boldness and long-range strategic planning on behalf of Twin Cities Orthopedics. This project brings increased access to ambulatory surgery physical therapy, clinical space, prosthetics, orthotics, fitness, and sports rehab to the area.

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JUNE 2021 MINNESOTA PHYSICIAN

HONOR ROLL 2021

Vance Thompson Vision Type of facility: Eye Care Clinic and Surgery Center Location: Alexandria, MN Ownership organization: Vance Thompson Vision, Dr. Deborah Ristvedt Architect/interior design: Sperides Reiners Architects, Inc.; Crawford Architect Engineer: Emanuelson-Podas Contractor: Innovative Builders of Alexandria, Inc Completion date: May 2020 Total cost: $4,435,930 Square feet: 12,500

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ance Thompson Vision is a premiere group of eye care and surgery professionals, specializing in the advanced treatment of cataracts and glaucoma, as well as oculoplastic surgery. Dr. Lowell Gess opened the Alexandria clinic in 1975 after completing missionary work as a general and eye surgeon in Sierra Leone.

His oldest son, Dr. Timothy Gess, went on to pursue ophthalmology and continued the practice. Today, the clinic is led by Timothy’s

daughter, board-certified ophthalmologist Dr. Deborah Ristvedt. The Gess-Ristvedt family has established a legacy of providing world-class care and advanced technology. With other clinics in Fargo, Sioux Falls, Bozeman and Billings, the new Vance Thompson Vision Eye Care Clinic and Surgery Center provides a patient-focused care and surgical environment that houses both a dedicated team as well as the latest in eye care equipment and technology.

Hello Progress Advancing health and wellness in local communities is at the heart of our endeavors.

612.524.6000 hdrinc.com

MINNESOTA PHYSICIAN JUNE 2021

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HEALTH CARE ARCHITECTURE

Children’s Minnesota Specialty Center - Lakeville Type of facility: Pediatric Specialty Center Location: Lakeville, MN Ownership organization: Children’s Minnesota Architect/Interior design: BDH Engineer: Hunt Electric - Mechanical and Plumbing: Horwitz Contractor: RJM Construction Completion date: January 2021 Total cost: $2,000,000 Square feet: 7,000

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hildren’s Minnesota Specialty Center Lakeville offers rehabilitation services including occupational therapy, physical therapy and speech therapy in a family-friendly environment for children of all ages. The center features patient rooms, colorful small gyms and meeting rooms. Children’s Minnesota believes children are more motivated when they are having a good time. Therefore, the team rehab sessions are as playful as possible. All the activities

-- from stacking blocks to playing with puppets -- are carefully chosen to help the child learn new skills or build on existing ones. In the coming months, the Lakeville location will add mental health services in the form of an adolescent partial hospitalization program designed to meet the needs of each individual child. Patients will have hours of therapy each day, but will return home with their families each night.

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JUNE 2021 MINNESOTA PHYSICIAN

HONOR ROLL 2021

Hennepin County: Behavioral Health and Wellness Center Type of facility: Behavioral Health Triage Clinic Location: Minneapolis, MN Ownership Organization: Hennepin County Architect/Interior design: Mohagen Hansen Architecture | Interiors Engineer: IMEG Corp.

Contractor: Carlson LaVine Construction Completion date: October 2020 Total cost: $5,170,000 Square feet: 13,0000

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he Behavioral Health & Wellness Clinic leverages the resources and expertise of county and community providers at one location with the potential to operate 24/7, 365 days a year. The renovation has resulted in space that offers support services in a dignified manner within a comfortable, calming setting.

The 13,000 sf clinic provides specialized triage services by assessing and individual’s level of need and referring individuals to the Withdrawal

Management Program, the new Mental Health Crisis Stabilization Program, community based social services, or to a hospital or emergency room.

The physical environment has a direct impact on behavior and the healing process. This has been universally substantiated and proves to be increasingly relevant as it relates to mental health settings and the overall well-being and safety of patients, family members, and healthcare staff.

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HEALTH CARE ARCHITECTURE

Shriners Children’s Twin Cities Type of facility: Ambulatory Center Location: Woodbury, MN Ownership organization: Shriners Hospitals for Children Architect/Interior design: DiGiorgio Associates, Inc and Stibler Associates, LLC Engineer: DiGiorgio Associates Inc, A LiRo Group Company Contractor: Timco Completion date: June 2020 Total cost: $1,785,000 Square feet: 18,000

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he Ambulatory Center provides pediatric orthopedic care to children and adolescents from the seven-state area. The interior design is derived from the Minnesota and Midwest landscape, providing a vibrant, pediatric feel. The “high-tech” and “high-touch” theme offers a friendly accessible atmosphere including interactive play areas, placing the child at the center of everything.

The design offers space-saving techniques, while addressing patient confidentiality and safety,

including dual entry exam rooms, dedicated staff and patient corridors, and collaborative workrooms replacing private offices. The singlefloor ambulatory center leads in the path toward outpatient-oriented healthcare delivery, offering the convenience of Provider Clinic, Orthotic & Prosthetic Services, Rehabilitation, Radiology and support services under one roof allowing Shriners Children’s to see more kids in more places, regardless of ability to pay.

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HONOR ROLL 2021

City Place II Type of facility: Multi-tenant Medical Office Building Location: Woodbury, MN Ownership Organization: Davis Architect/Interior design: Synergy Architecture Studio/ BDH Interior Design Engineer: KOMA (structural) Loucks (civil and landscape) Contractor: Timco Completion date: June 2020 Total cost: $6,500,000 Square feet: 43,500

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ity Place II is the second medical tenant office building in the Woodbury City Place neighborhood developed by Davis. The 43,500 square foot building is a class ‘A’ medical office building clad in beautiful stone, brick, metal and an abundance of glass.

The inclusion of walking paths with a variety of landscaping, a cover drop off and pick up canopy, warm and welcoming interior finishes and abundance of natural light all contribute to

a wonderful patient experience. Shriners Health Care for Children selected City Place II for their new home in the Minneapolis and St. Paul region and the OB/GYN practice of Adefris and Toppin moved their clinic to this new location.

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3The Future of Rural Healthcare from page 15 Ideally, they need a campus or clinic designed with an integrated model of care where they can easily navigate between all appointments in a single trip. The current push for decentralized community care and reducing the number of steps between appointments is only the beginning. Ambulatory care centers with expanded outpatient care are creating new options that gravitate away from the hospital into smaller, freestanding medical office buildings that include amenities such as retail, coffee shops, and fitness.

Moorhead’s Sanford Clinic is a prime example as it’s optimally located to serve both the Fargo-Moorhead community and surrounding rural areas.

Because of the nature of the location, the 49,250 square-foot clinic is extremely patient-focused, offering a wide range of services including a pharmacy, a large imaging suite, a full-service laboratory, and an area dedicated to occupational medicine. All of these services under one roof, combined with a medical home model, allows for ease of use and efficiency for all patients.

Their team understood the impact of accessing multiple specialists and the way this model would positively affect their patients and healing process.

For rural healthcare systems that don’t have the luxury of a multiplebuilding campus or access to a wide variety of providers, “neighborhoods” within a single building provide individualized outpatient services without the sterile feel of a traditional hospital. Smaller communities can see big benefits with “coopetition,” individual practitioners sharing costs throughout a unified space. The loss of a larger retailer or grocery branch can offer cost efficient possibilities in terms of creating a new health care delivery center.

Pathways While advances in telehealth, wearables, and virtual hospitaling have propelled us through a pandemic, they’re also game changers for future-proofing rural healthcare. In the past, rural hospitals sent patients out of the community for hospital-based or specialty services. Today, we can fast-track the ability to connect patients and providers for a more comfortable, “close to home” healthcare experience. This isn’t simply a matter of rural regions gaining better access to high-speed internet, the responsibility also lies with designers and practices to incorporate designated telehealth offices with integrated technology, privacy, lighting, acoustics, and a minimal, but soothing backdrop.

This is a pandemic ripple effect that the industry must emphatically embrace.

Part of this embrace must be the continued investment from third party payers in reimbursement for telehealth services at rates similar to those for providing in-person care. Federal oversight, relaxed guidelines, and CMS pandemic response helped drive the initial telehealth boom and local payers fell in line. As data continues to grow supporting the efficacy and value of telehealth, particularly in rural communities, these new tools must be utilized in ways that are fair to providers and patients. It is important for telehealth to remain in the hands of local providers and not turned into another avenue of narrow networks, restricted access, and non-transparent pricing. New ways of measuring quality in telehealth care are emerging, as are ways of protecting the public from malpractice through telehealth. It is vital for physicians and health plans to be involved with these developments.

The Future of Rural Healthcare to page 284

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PHYSICIAN

THE INDEPENDENT MEDICAL BUSINESS JOURNAL

Volume XXXII, No. 05

CAR T-cell therapy Modifying cells to fight cancer

BY VERONIKA BACHANOVA, MD, PHD

U

niversity of Minnesota Health is now among the few selected centers in the nation to offer two new immunotherapy drugs for the treatment of diffuse large B-cell lymphoma.

Both drugs—Yescarta and Kymriah—are part of an emerging class of treatments, called CAR T-cell therapies, that harness the power of a patient’s own immune system to eliminate cancer cells.

Physician/employer direct contracting

CAR T-cell therapy involves drawing blood from patients and separating out the T cells. Using a disarmed virus, the patient’s own T cells are genetically engineered to produce chimeric antigen receptors, or CARs, that allow them to recognize and attach to a specific protein, or antigen, on tumor cells. This process takes place in a laboratory and takes about 14 days. After receiving the modification, the engineered CAR-T cells are infused into the patient, where they recognize and attack cancer cells. Kymriah received initial FDA approval in 2017 for the treatment of pediatric acute lymphoblastic leukemia.

BY MICK HANNAFIN

ith the continuing escalation of health care costs, large and midsized selfinsured employers are once again looking for an edge to manage their medical plan costs and their bottom line. They understand that they are ultimately funding health care as they pay for their population’s claims.

CAR T-cell therapy to page 144

• •

Many of these employers have employed the same overarching set of strategies: shop for a new carrier that is willing to lower the administrative costs or underprice the risk, Physician/employer direct contracting to page 124

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• • • • •

Great Opportunities

JUNE 2021 MINNESOTA PHYSICIAN

(612) 728-8600

763-682-5906 | 763-684-0243 michelle@whitesellmedstaff.com www.whitesellmedstaff.com

Unique Practice Opportunity Join an established independent internal medicine practice Be your own boss in a collaborative business model with a healthcare philosophy that puts patients first and allows physicians to have complete control of their practice.

SHARE YOUR INSPIRATION.

The specialties we are looking for are: Internal Medicine, Family Practice, Preventive Medicine, Cardiology, Dermatology, Allergist, or any other office-based specialty.

Preferred Credentials are MD, DO, PA, and NP. • Beautiful newly remodeled space in a convenient location • Competitive Wages and a great Professional Support Staff

On the U.S. Army health care team, you will enjoy the satisfaction of providing quality care to Soldiers and their families, in a setting with innovative technologies, robust resources and a dedicated, supportive team.

Learn more at healthcare.goarmy.com/nz72 Contact Mitchell for more information | mitch@brandtmgmt.com 6565 France Ave S Ste 350 Edina

©2018. Paid for by the United States Army.

All rights reserved.

CARRISHEALTH IS THE PERFECT MATCH Carris Health is a multi-specialty health network located in west central and southwest Minnesota and is the perfect match for healthcare providers who are looking for an exceptional practice opportunity and a high quality of life.

INTERESTED BE/BC PHYSICIANS IN THE FOLLOWING SPECIALTIES, PLEASE INQUIRE WITH US FOR MORE DETAILS. • • • • • •

Anesthesiology Dermatology ENT Family Medicine Gastroenterology General Surgery

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Hospitalist Internal Medicine Nephrology Neurology OB/GYN Oncology

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Orthopedic Surgery Pediatrics Psychiatry Psychology Urgent Care Urology

Loan repayment assistance available.

FOR MORE INFORMATION: Shana Zahrbock, Physician Recruitment Shana.Zahrbock@carrishealth.com (320) 231-6353 | carrishealth.com Laamy Tiadjeri, MD – Obstetrics & Gynecology, Willmar, MN

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3The Future of Rural Healthcare from page 26 Health plans are also taking steps to help rural practices transition to a value-based reimbursement model that pays more for keeping patients healthier than using the old fee-for-service volume-based model. By providing both practice support and technology, new care coordination programs are helping to specifically address the problems of multiple chronic conditions that are so common in rural healthcare.

Beyond the building Architects and designers have a growing responsibility in addressing healthcare delivery, research, and equity. With post-pandemic rural communities in a state of change, one of the most important pieces is to start looking at the data from the heart of the pandemic. Rural communities are going to be different, both qualitatively and quantitatively. Unfortunately, the quantitative data that is currently available is extremely outdated. It is crucial to create new methods of collecting data to help better advocate for the needs of the community. One such initiative is the UC Berkley Center for the Built Environment – a platform that offers robust tools for postoccupancy evaluations. They offer a deeply research-based approach with cutting edge exploration around how the built environment impacts human health, wellness, and resilience.

Redefining the role of the design professional to think “Beyond the Building” is increasingly valuable. Architectural firms need to serve healthcare clients outside of the brick and mortar and start setting the stage as strategic partners; partners who look at building great community connections.

In the architectural industry, a strong emphasis will also need to be placed on dignity, equity, and the positive impact of design to uplift humanity and community collectively. Design is a force for change. Earlier involvement for architects, designers, and community members in the design process will lead to more solution-sensitive concepts, ideas, and master plans. When design professionals are engaged at the forefront, they can effectively gather initial community input and use their expertise to lead to a well-rounded solution. Ideally, design involvement doesn’t end after project completion, but rather continues throughout post-occupancy evaluations to address improvements and future positive change.

When it comes to defining strategies for improving rural healthcare, we now have more informed pathways than ever before. By embracing innovation and elevating design partnerships, rural healthcare can respond positively to its many challenges and achieve unprecedented positive outcomes in overall population health, wellness, access, and research.

Todd Medd, AIA, is a Principal Architect, Healthcare Practice Studio Leader, and a passionate rural healthcare thought leader at JLG Architects.

Kristine Sallee, CID, LEED AP ID+C, WELL AP, EDAC and EvidenceBased Design Accredited Professional, is a Healthcare Designer and Client Relationship Manager at JLG Architects.

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 Cardiology • Cardiologist • Internal Medicine/Family Practice • Gastroenterologist • Psychiatrist

Ely VA Clinic

Hibbing VA Clinic

• Tele-ICU (Las Vegas, NV)

Current opportunities include:

Current opportunities include:

• Nephrologist

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

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JUNE 2021 MINNESOTA PHYSICIAN

•

www.minneapolis.va.gov

YOU’D MAKE A REALLY GOOD DOCTOR IF YOU WEREN’T BEING AN OFFICE MANAGER.

Primary Care We are an independent physician-owned multi-specialty practice with 180 providers located across 13 sites, and-state-of-the-art facilities. Recently voted one of the 14 coolest urban spaces in America, Mankato is a short drive from the metro with abundant nearby recreation opportunities, safe, charming and affordable neighborhoods, outstanding schools and a thriving arts community.

We offer highly competitive compensation, generous benefits and a career choice you will never regret. Leave the burnout and stress behind. We can design a work schedule around your needs and let you concentrate on what you do best – by taking care of patients.

If you would lie to learn more please contact:

Dennis Davito Director of Provider Services 1230 East Main Street Mankato, MN 56001 507-389-8654 dennisd@mankatoclinic.com

For more information, contact TSgt James Simpkins 402-292-1815 x102 james.simpkins.1@us.af.mil or visit airforce.com

Apply online at www.mankatoclinic.com

©2013 Paid for by the U.S. Air Force. All rights reserved.

With more than 35 specialties, Olmsted Medical Center is known for the delivery of exceptional patient care that focuses on caring, quality, safety, and service in a family-oriented atmosphere. Rochester is a fast-growing community and provides numerous cultural, educational, and recreational opportunities. Olmsted Medical Center offers a competitive salary and comprehensive benefit package.

Opportunities available in the following specialties: • Active Aging Services - Geriatric Medicine/Palliative Care • Dermatology • ENT - Otology

• Family Medicine • Gastroenterology • Pediatrics

• Psychiatry - Adult • Psychiatry - Child & Adolescent • Rheumatology

Equal Opportunity Employer / Protected Veterans / Individuals with Disabilities

Send CV to: Olmsted Medical Center Human Resources/Clinician Recruitment 210 Ninth Street SE, Rochester, MN 55904

email: dcardille@olmmed.org • Phone: 507.529.6748 • Fax: 507.529.6622

www.olmstedmedicalcenter.org MINNESOTA PHYSICIAN JUNE 2021

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3Fifty Years of Health Care Quality Innovation from page 9 What are some of the most rewarding projects you have worked on since becoming CEO?

My daily reward is knowing that we make lives better. To work in health improvement, it’s important to be an optimist – to believe that things can be better and that our actions make a difference.

At Stratis Health, I get to work with a smart and compassionate team of optimists who believe in our mission and work; and I have the opportunity to authentically engage with the communities and people we serve. As a result, it’s impossible to call out the most rewarding projects since I became CEO in 2006. While there are certainly hard days and difficult projects, I’m rewarded in the moment by whatever combination of initiatives we have in front of us on any given day and am always looking ahead to see how we can be even more relevant and responsive. My role is to continue to lead with vision.

When you find yourself in a non-professional social situation and you have to explain what you do for work, what do you say?

Stratis Health improves health through

collaboration and innovation. We are an organization breaking down care delivery silos and building bridges between health care and community, often for vulnerable and underserved populations. As the president & CEO, it’s my job to ensure we maintain our results-driven culture and firmly support our dedicated staff and Board members who have guided the organization and implemented our work for the past five decades.

Improving health care quality is a vast and complex topic. What are some examples of how your work helps physicians provide better patient care?

Improving health care is indeed vast and complex!

Physicians have a key role in care improvement, and it’s been our privilege to be working alongside physicians over the 50 years of Stratis Health. In the past, we have supported physicians in providing better care by accelerating the translation of research to practice such as the use of standing orders and redesigned workflow; facilitated efficient and effective adoption and optimization of electronic health records; and collaboratively established statewide standards and protocols to improve care transitions

Three patients.

Who is at risk for diabetes?

focused on such things as medication reconciliation and discharge planning. Today, we assist physicians to be successful in new payment programs that reward for quality through our MIPS Estimator tool and technical assistance, and to be able to understand and be responsive to the increasingly diverse patients they care for through Culture Care Connection.

We lead the Minnesota Shared Decision-Making Collaborative to adopt and promote the routine use of shared decision-making in clinical practice, and launched the Minnesota Serious Illness Action Network last year to share new and emerging practices, tools, and resources relevant for front-line clinicians in the COVID-19 pandemic. And we are just getting started in new work to engage physicians to improve access to medication-assisted treatment for opioid use disorder in underserved communities in Minnesota. We are grateful to our physician partners and champions.

Jennifer P. Lundblad, PhD, MBA is the President and CEO of Stratis Health, an independent nonprofit organization that leads collaboration and innovation in healthcare quality and safety.

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

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JUNE 2021 MINNESOTA PHYSICIAN

IT’S TIME TO EXPECT MORE FROM YOUR MEDICAL LIABILITY INSURANCE COMPANY.

More means combining insurance protection with unique claims analytics and risk management.

So providers can reduce distractions and focus on improving outcomes.

Coverys is rated A (Excellent)* and has over 45+ years’ experience protecting healthcare.

Visit coverys.com.

*A.M. Best financial rating is held by Medical Professional Mutual Insurance Company and its insurance subsidiaries.

COPYRIGHTED. Insurance products issued by ProSelect® Insurance Company (NE, NAIC 10638) and Preferred Professional Insurance Company® (NE, NAIC 36234).

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Sofia Lyford-Pike, MD

TRANSFORMING HEALTH & MEDICINE Leaders • Educators • Innovators

mphysicians.org