MN Physician June 2016 by Minnesota Physician Publishing

Vo l u m e X X X , N o . 3 J u n e 2 016

Changes in clinical practice The role of telecommunications technology By Christine Guzzo Vickery, CID, EDAC, and Douglas Whiteaker, AIA, LEED AP

lectronic telecommunications technology is expanding exponentially, increasing opportunities for mobile health care delivery. Fitbits, smart watches, and health apps deliver health care data to our touchscreen devices while we are on the go. We can track our steps, check our heart rate, access lab results, and consult with a physician without actually walking into a clinic. The accessibility of health care information helps fuel the growing focus on wellness and population health.

Targeted temperature management Improving outcomes in neurocritical care By Charles R. Watts, MD, PhD “A learning experience is one of those things that say, ‘You know that thing you just did? Don’t do that.’” Douglas Adams, The Salmon of Doubt

he tissues of the central nervous system (CNS), including the spinal cord, are some of the most metabolically active in the human body. Approximately 20 percent of an

individual’s cardiac output and 20 to 25 percent of the body’s oxygen consumption is used to support the central nervous system, which is entirely dependent on oxidative metabolism. Of that high energy requirement, approximately 45 percent goes to cellular maintenance and 55 percent to nerve impulse generation and transmission. Targeted temperature management to page 10

In many instances, health care organizations are both the driver and the follower of new technology. Private industry is developing, marketing, and distributing new technology and software at an increasing pace, and health care organizations are integrating this new technology into the health care delivery process — offering countless benefits to patients inside and outside the clinic. Changes in clinical practice to page 12

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JUNE 2016 • VOLUME XXX, NUMBER 3

MINNESOTA HEALTH CARE ROUNDTABLE

FEATURES Targeted temperature management Improving outcomes in neurocritical care

FORTY-SIXTH SESSION

By Charles R. Watts, MD, PhD

Changes in clinical practice 1 The role of telecommunications technology By Christine Guzzo Vickery, CID, EDAC, and Douglas Whiteaker, AIA, LEED AP

Value - Based Purchasing:

A new way to pay for health care

DEPARTMENTS CAPSULES 4 RADIOLOGY MEDICUS

INTERVIEW

Lung cancer screening By Aaron Binstock, MD

Conscious sedation Paul Sorajja, MD, FACC, FAHA, FSCAI Minneapolis Heart Institute at Abbott Northwestern Hospital

Thursday, November 3, 2016 • 1:00-4:00 PM

The Gallery (lobby level), Downtown Minneapolis Hilton and Towers

PROFESSIONAL UPDATE: RHEUMATOLOGY Seronegative Sjogren’s syndrome By Parastoo Fazeli, MD

2016 HEALTH CARE ARCHITECTURE HONOR ROLL Eleven outstanding building projects By MPP Staff

SPECIAL FOCUS: MEDICAL FACILITY DESIGN Designing clinical team spaces By Allison Matthews, MArch

18 Substance use disorder

treatment centers By Richard P. Engan, AIA, LEED AP, CID, and Mitra Milani Engan

www.mppub.com

Background and Focus: As initiatives driven by federal health care reform move forward, the term “Value-Based Purchasing” (VBP) is being applied to a wide spectrum of issues. But what does this mean? CMS is developing measurements, well over 150 to date, to define what “value” means in health care. It is proposed that these metrics will be used to create incentives that pay more for better care in every element of health care delivery. Hospitals, physician practices, home care, and long-term care will all be reimbursed by an emerging new math. Objectives: We will explore the motivations behind this changing approach to purchasing health care. We will examine what is being measured and what value really means. We will discuss the arguments that claim VBP is a bad idea and those that believe it is the best solution. We will discuss how a collaborative, transparent system, that integrates care teams, health information technology, and improved reimbursement methods will help achieve increased access to high-quality, cost-effective care for patients. Panelists include: • Curtis Hanson, MD, Chief Medical Officer, Mayo Medical Laboratories Sponsors include: • Athena Health • Mayo Medical Laboratories Please send me tickets at $95.00 per ticket. Tickets may be ordered by phone at (612) 728-8600, by fax at (612) 728-8601, on our website (mppub. com), or by mail. Make checks payable to Minnesota Physician Publishing. Mail orders to MPP, 2812 East 26th Street, Mpls, MN 55406. Please note: tickets are non-refundable.

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CAPSULES

New Law Improves Caregiver Training Gov. Mark Dayton has signed the CARE (Caregiver Advise, Record, Enable) Act into law, which will require hospitals to provide patients the opportunity to designate a caregiver and provide that caregiver with a discharge plan and aftercare instructions. The caregiver must be kept informed about the patient’s status and provided with an explanation and demonstration of the medical tasks they will need to perform at home after leaving the hospital. “Caregivers are performing more and more complex medical tasks that used to be provided by an at-home nurse,” said Seth Boffeli, communications director of AARP Minnesota. “If we’re going to ask them to do more, we need to better prepare them.” The bill passed the Senate last year and passed the House in early May this year with a unanimous vote. It will go into effect in 2017 and affect more than 670,000 unpaid family caregivers, according to AARP. More than 20 other states have passed similar legislation. The Minnesota Hospital Association worked with the bill’s

authors — Sen. Kent Eken (D-Twin Valley) and Rep. Nick Zerwas (R-Elk River) — to add verbiage to the bill that protects hospitals from litigation for care provided by a designated caregiver and an ability for hospitals to deny the caregiver designation if it is determined that they are unable to perform the duties called for in the discharge plan. It also omitted the requirement of procuring a second written consent for sharing the individual’s health record information with the designated caregiver.

Allina to Combine Mercy and Unity Hospitals Allina Health System has announced that its Unity Hospital in Fridley and Mercy Hospital in Coon Rapids will operate as one hospital starting Jan. 1, 2017. The two will share the name Mercy Hospital and Unity Hospital will be known as Mercy Hospital– Unity Campus. The goal is to strengthen specialty services and reduce unnecessary duplication at the hospitals. Allina Health is calling the plan “One Hospital, Two Campuses.”

MINNESOTA PHYSICIAN JUNE 2016

The health care system plans to spend about $103 million on construction projects at both hospitals. Plans are still being finalized and will take place over the next several years. At Mercy Hospital, projects could include renovating the parking ramp and intensive care unit as well as expanding operating rooms and emergency departments. Projects at the Unity Campus include expanding the emergency room and inpatient mental health clinic, as it will merge with Mercy’s mental health services unit. Consolidating the mental health care unit at Unity alone will cost Allina Health about $17.5 million next year. According to Allina Health, more than 60 percent of the hospitals’ mental health patients also struggle with addiction issues. The move, meant to help improve access to care for these patients, will take place in early 2017. “We are making a significant investment to improve access to mental health professionals and services,” said Helen Strike, president of Unity Hospital. “Improved access in our primary care and mental health clinics will help to avoid a crisis.”

Mayo Clinic Joins National Microbiome Initiative Mayo Clinic has announced it has joined the new National Microbiome Initiative sponsored by the White House Office of Science and Technology Policy and has committed to opening a new clinic based on microbiome science as part of the project. The $1.4 million clinic will focus on improving patient care through diagnostics, therapeutics, and education based on microbiome science. Diagnostics at the clinic will include whole-genome sequencing, antibiotic-resistance profiling, metagenomic profiling, targeted environmental testing, and 16S rRNA-gene based tests to individualize treatment of undiagnosed infections and conditions, as well as to perform hospital surveillance, according to a fact sheet about the initiative. Therapeutics will include Mayo Clinic’s established fecal microbiota transplant program, and new therapies emerging from clinical trials and education will focus on helping patients navigate the complex options that promote

One in Three Antibiotic Prescriptions May Be Unnecessary Between 2010 and 2011, an estimated 30 percent of outpatient antibiotic prescriptions in the U.S. were unnecessary, according to a new study. Eva Enns, PhD, an assistant professor at the University of Minnesota School of Public Health’s division of health policy and management, worked with researchers at the Centers for Disease Control and Prevention (CDC) as well as various U.S. colleges to determine how many outpatient visits had antibiotics inappropriately prescribed. “Antibiotic resistance is increasing — we are seeing the emergence of infections that are resistant to all available treatments,” said Enns. “Luckily these are still rare, but MRSA, one of the most publicized cases of antibiotic resistance, was once a rare condition, too, limited to inpatient settings. But now we’re seeing it more and more, even in community settings.” The researchers analyzed data from the 2010–2011 National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey, which showed that nearly 262 million total outpatient antibiotic prescriptions were sold throughout the year. That’s an annual antibiotic prescription rate of 506 per 1000 population. Based on clinical guidelines and geographic variation in prescribing, they estimated the proportion of antibiotic prescriptions that were likely

inappropriate, which was 153 of 506, or about 30 percent. “Antibiotic resistance is an inevitable consequence of antibiotic use, both appropriate or inappropriate,” said Enns. “The key is to conserve antibiotics for the cases in which they are truly needed.” Antibiotic resistance causes 23,000 deaths each year, according to the CDC, and the White House has implemented the National Action Plan for Combating Antibiotic-Resistant Bacteria, which has a goal of reducing inappropriate antibiotic use by 50 percent by the year 2020. The results of this study offer a baseline to monitor and compare progress in the future. “For prescribers, we try to make the point that prescribing antibiotics is not without consequences and should not be used ‘just in case,’” said Enns. “If they believe an antibiotic would be beneficial, they should provide the diagnosis that would justify it.”

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Rogers Now Open in Minneapolis Rogers Behavioral Health is making mental health treatment even more accessible with the May 23rd opening of our Eden Prairie location. Offering specialized outpatient treatment six hours a day, five days a week, for OCD and anxiety, depression and other mood disorders.

Abbott to Acquire St. Jude Medical Abbott Laboratories has reached a deal to acquire medical device maker St. Jude Medical for about $25 billion. The companies reached a cash and stock agreement to create a global cardiovascular care company — shareholders of Little Canada-based St. Jude will get $46.75 in cash and 0.8708 shares of Abbott common stock, a value totaling about $85 per share. Abbott will assume or refinance St. Jude Medical’s $5.7 billion of debt. “Together, the company will compete in nearly every area of the cardiovascular market and hold the No. 1 or 2 positions across large and high-growth cardiovascular device markets,” the companies said in a statement. The deal is subject to approval by shareholders and regulators of St. Jude Medical. If the transaction is completed, the companies expect sales in the cardiovascular device market to be about $8.7 billion. Details are expected to be finalized by the end of 2016. The companies have not confirmed whether the acquisition will affect the 3,000 St. Jude jobs at its headquarters in Little Canada and locations in Minnetonka, Plymouth, and Roseville, but have indicated that they do not expect significant workforce changes in Minnesota. Capsules to page 6

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Telephone Equipment Distribution (TED) Program

health and wellness, including diet, nutritional supplements, and probiotic foods. The initiative was announced on May 13 with the goal of supporting interdisciplinary research, developing new technologies, and expanding the workforce in microbiome studies. In addition to opening the microbiome clinic, Mayo Clinic is also one of seven founding entities that have come together to launch the Microbiome Coalition as part of the national initiative. The coalition aims to promote a greater public understanding of the microbiome as it relates to human health and wellness as well as facilitate discussions among key stakeholder groups.

Do you have patients with trouble using their telephone due to hearing loss, speech or physical disability? 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 ted.program@state.mn.us 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 JUNE 2016 MINNESOTA PHYSICIAN

Capsules from page 5

Uninsured Rate Drops The uninsured rate in the U.S. fell to 9.1 percent in 2015, according to data from the Centers for Disease Control and Prevention’s latest National Health Interview Survey, which estimates health insurance coverage based on data for 103,798 people in the U.S. and the District of Columbia. It is the first year that less than one in 10 Americans have lacked health insurance. “Today’s report is further proof that our country has made undeniable and historic strides thanks to the Affordable Care Act,” said HHS Secretary Sylvia Mathews Burwell. “The uninsured rate fell to 9.1 percent in 2015, making it the first year in our nation’s history that fewer than one in 10 Americans lacked health insurance, and the report documents the progress we’ve made expanding coverage across the country. Meanwhile, premiums for employer coverage, Medicare spending, and health care prices have risen at exceptionally slow rates.” Minnesota’s uninsured rate reached 4.3 percent in 2015 — a

notable drop from 8.0 percent in 2014 and 9.7 percent in 2013. The most recent data also shows that in 2015, 24.3 percent had public health plan coverage and 81.1 percent had private health insurance coverage. Adults ages 18 through 64 had an uninsured rate of 6.4 percent, with 9.7 percent having public health coverage and 84.5 percent having private coverage. In the Midwest region, there was an overall uninsured rate of 10 percent. The region with the lowest rate was the Northeast with 8.1 percent, and the highest was the South with 17.3 percent.

HealthPartners Funded to Continue Blood Pressure Study HealthPartners Institute has received a $6 million award from the Patient-Centered Outcomes Research Institute to continue work on a high blood pressure study in which researchers are working to determine whether telemonitoring blood pressure from home with a direct link to a pharmacist or nurse practitioner

in addition to regular primary care appointments can improve a patient’s blood pressure and overall health. Patients in the study are given a blood pressure measuring device to use at home and readings from the device are sent six times per week, allowing medical personnel to adjust individual treatment. Typically, fewer primary care visits are needed when telemonitoring is in place. “We are really excited that we are able to continue on with this line of research,” said Karen Margolis, MD, MPH. “A two- to threepoint drop in a blood pressure reading over a sustained period can make the difference between having or not having a stroke or heart attack.” This is the third phase of the study, called HyperLink. The first two phases showed that patients who used home telemonitoring reached double the rate of blood pressure control over the next year than those who did not use home telemonitoring. In phase three, the $6 million award will be used to expand the scope of the study to include data from a larger sample of patients.

HealthEast Planning Multispecialty Center in Maplewood HealthEast has announced that it will be the lead tenant in a three-story, 80,000-square-foot multispecialty center in Maplewood, near St. John’s Hospital. The health care system is still finalizing plans for the space, but says it will support its vision for primary care and ambulatory surgery. “Our vision is to reimagine the outpatient experience and establish an exceptional destination that will optimize care coordination and patient flow,” said Eric Nelson, vice president of operations for ambulatory care and medical services at HealthEast. The Davis Group, a Minneapolis-based real estate brokerage and consulting company specializing in health care facilities, owns the building and is funding the construction project. Work could begin as early as August, pending approval from the Maplewood City Council.

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MEDICUS Dania Kamp, MD, has been named the new president of Minnesota Academy of Family Physicians (MAFP). As president, she will serve as the official representative and spokesperson for MAFP, serve on the board of directors, and chair the executive committee of the board of directors. Kamp is chief of staff at Mercy Hospital and a family practitioner at Gateway Family Health Clinic, both located in Dania Kamp, MD Moose Lake. She specializes in maternal health, including obstetrical care; child and adolescent health; preventive medicine; hospice and palliative care; and health care policy. She works with patients of all ages in many settings, including clinics, emergency rooms, and nursing homes. Kamp earned her medical degree at the University of Minnesota and completed a residency at Oregon Health and Science University in Portland. Lawrence Lee, MD, has been hired as UCare’s senior vice president and chief medical officer. In his new position, Lee will have overall responsibility for UCare’s clinical and quality practices and medical policies as well as oversee the medical director team and UCare’s pharmacy, clinical services, and quality management departments. Previously, Lee spent a year as a staff physician Lawrence Lee, MD and clinical educator with the Veterans Health Administration in Minneapolis. He has also served as vice president and executive medical director for quality and provider relations at Blue Cross and Blue Shield of Minnesota; associate health plan medical director at HealthPartners; national medical director for transparency and designation programs at UnitedHealthcare, and staff internal medicine physician and assistant professor at Mayo Clinic in Rochester. Lee earned his medical degree at Harvard Medical School and a master in business administration in health care management degree at Wharton School of the University of Pennsylvania. Fredric Meyer, MD, has been selected as the Juanita Kious Waugh Executive Dean for Education at the Mayo Clinic College of Medicine, effective July 1. Meyer will lead the educational strategies and direction of the Mayo Clinic College of Medicine schools around the country and assume the role of dean of Mayo Medical School. He currently serves as enterprise chair of Fredric Meyer, MD the department of neurology at Mayo Clinic, the Alfred Uihlein Family Professor of Neurologic Surgery within the College of Medicine, and executive director of the American Board of Neurological Surgery. His previous experience includes serving as program director of the Neurologic Surgery Program at Mayo School of Graduate Medical Education, a member of the Accreditation Council for Graduate Medical Education, president of the American Academy of Neurological Surgery, and chair of the American Board of Neurological Surgery. Meyer earned his medical degree at Boston University and completed his residency at Mayo School of Graduate Medical Education. He has been with Mayo Clinic since 1987. Cody Wendlandt, MD, has been elected by his fellow residents to serve as chief resident of the University of Minnesota/St. Cloud Hospital Family Medicine Residency Program for the 2016– 2017 academic year. He will assume the role on July 1. He is a member of the American Academy of Family Physicians and his professional interests include clinical workflow, health care policy, rural Cody Wendlandt, MD medicine, and emergency medicine. Wendlandt earned his medical degree at St. George’s University in Grenada, West Indies, and completed clinical rotations at St. Joseph Regional Medical Center in Paterson, New Jersey.

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6/2/16 11:42 AM

INTERVIEW

Conscious sedation

Paul Sorajja, MD, FACC, FAHA, FSCAI Minneapolis Heart Institute at Abbott Northwestern Hospital Dr. Sorajja is a cardiologist, researcher, and director for the Center of Valve and Vascular Heart Disease at the Minneapolis Heart Institute at Abbott Northwestern Hospital. He has authored more than 150 manuscripts. His research interests are in valvular heart disease, transcatheter valve therapy, structural heart interventions, and hypertrophic cardiomyopathy. He completed medical school and residency at the Mayo Clinic College of Medicine in Rochester and completed fellowships at Mayo and St. George’s Hospital Medical School in London.

T ell us how conscious sedation started. How widely used is it? Conscious sedation started several years ago to minimize morbidity for patients undergoing transcatheter aortic valve replacement (TAVR). Conscious sedation is distinct from general anesthesia and is not the same as monitored anesthesia care (MAC). The sedatives in conscious sedation are even less than what one typically administers for an endoscopy. It’s an important advance in this therapy, as patients who have TAVR are typically elderly, frail, and can have a number of challenges with post-operative recovery. Our patients have been very pleased with the pain control and avoiding intubation while having their aortic valve replaced. Conscious sedation TAVR is available at only a few centers across the country, and it’s the principal way we do our procedures at the Minneapolis Heart Institute at Abbott Northwestern Hospital. P lease describe how conscious sedation differs from general anesthesia? Conscious sedation consists of two main medications: a narcotic analgesic and a benzodiazepine. Doses are small; for example, 25–50 mcg for fentanyl and 0.5–1.0 mg for midazolam. In addition, a generous amount of local anesthesia is given to the vascular access site. Unlike general anesthesia, there is no need to intubate the patient, and the impact on mentation and its recovery is minimal. The patients are fully conversant and participate in the procedure to let us know how they’re doing. Conscious sedation is routinely administered by a registered nurse, certified registered nurse anesthetist (CRNA), or anesthesiologist. P lease describe aortic valve stenosis and its risk factors. Aortic stenosis is very common, and the prevalence is increasing with our aging population. In Minnesota, there are over 25,000 people with severe aortic stenosis. These patients have a very poor prognosis without surgery. Once symptoms begin, survival is only one to two years. The survival rate is worse than that of many malignancies, including advanced breast cancer. Surgery is lifesaving in individuals with aortic stenosis; yet, for a variety of reasons, the vast majority of people with aortic stenosis go untreated. Given the large number of these individuals and the availability of therapy for the entire spectrum of surgical risk, untreated aortic stenosis should be considered a public health crisis. We need to be more aware of how poorly patients do without surgery and how this safe procedure saves and improves lives.

MINNESOTA PHYSICIAN JUNE 2016

H ow do TAVRs differ from other valve replacement procedures? TAVR is a lifesaving procedure in which the aortic valve is replaced using a femoral artery (or other vessel) as opposed to performing a cardiopulmonary bypass or traditional sternotomy. The major benefit of TAVR is the low risk and that patients can be discharged one to two days afterward. With this technology and when performed in skilled centers, the procedural mortality is only 1 to 2 percent. This is remarkable given the high-risk nature of many patients with aortic stenosis. TAVR is available for all patients who are at high risk for open surgery. Patients who are at low or intermediate risk can have TAVR by participating in current research trials. W hich patients are the best candidates for TAVRs performed under conscious sedation? Many patients prefer to avoid intubation and enjoy the faster recovery that occurs with conscious sedation. This motivation is very helpful as patients need to lie still during the procedure. Some patients cannot have conscious sedation TAVR for a variety of reasons, most commonly because of the need for TAVR to be performed using a transaortic or transapical approach. Other patients may not be able to lie supine comfortably. Some patients also prefer to be asleep during the procedure, and general anesthesia is used for them. H ow has this procedure affected hospitalization and recovery times? Recovery times are much quicker with conscious sedation, as these patients remain fully awake. Fewer invasive arterial lines are required, and patients are dismissed from the procedure room directly to telemetry, bypassing the PACU and the ICU. Procedure setup time and room turnover has significantly decreased. These practice changes have led to significant savings in resources such as personnel, room utilization, and hospitalization costs. W hat special training and experience does the surgeon require? All physicians who perform TAVR undergo training programs specific to the therapy. There are a variety of TAVR valves in current use, and regular training is done to maintain proficiency in the nuances of these valves and their delivery systems. For performing TAVR with conscious sedation, it’s important that the physicians, surgeons included, continually interact with the patient to ensure patient comfort throughout the procedure. At multiple points, such as vascular access or valve deployment, the patient is verbally guided.

 How many conscious sedation  I f there are complications during newer methods for percutaneous delivery procedures have been performed at conscious sedation, is the patient have been developed in the past several the Minneapolis Heart Institute? switched to general anesthesia? years. Last year, we were the first center in the U.S. to perform transcatheter miWhile we have been doing TAVR with MAC All procedures are performed in hybrid optral valve replacement (TMVR) without erating rooms, where patients can be imme- for years, we began conscious sedation cardiopulmonary bypass in a patient with diately placed under general anesthesia and for these cases earlier this year. Thus far, mitral regurgitation. This was a remark40 percent of our eligible patients have receive the care they need to address any able advance. The mitral valve prosthesis complications that arise. A multidisciplinary undergone TAVR with conscious sedation, was placed through a left thoracotomy, and team has immediate access to tools for sup- and that number will rise sharply in 2016. there was complete elimination of port, such as emergency cardiopulthe regurgitation. The TMVR procemonary bypass. Although the risk of dure took less than 60 minutes even TAVR has become low, complications Untreated aortic stenosis should be though the procedure was being can be catastrophic, and it’s importconsidered a public health crisis. performed for the first time. This ant for the team to be fully prepared therapy, like many others in valve disfor these situations. ease, is evolving further, and I believe  Do you expect conscious sedation to many other procedures besides TAVR will be W hat other surgical procedures would become the standard approach to performed with conscious sedation. be appropriate for conscious sedation? performing TAVRs? Most interventional cardiology procedures,  What does the future hold for TAVR is a very safe procedure. The procesuch as coronary stent placement or congenconscious sedation? dure can be completed in under 45 minutes, ital therapies, are currently performed with It’s very bright. We’ve seen a remarkable and the transfemoral route can be used in conscious sedation. Some valve therapies transformation in how valve therapy has over 90 percent of patients. Given the safety are performed with conscious sedation. evolved over the past several years. Not long of this procedure, patient preference for Otherwise, for surgical valve replacement, ago, there were few options for patients with avoiding general anesthesia, and the inTAVR is the only procedure performed with valve disease, and many of these patients creased procedural efficiency and potential conscious sedation. could not or were unwilling to undergo a for savings in resources, I believe that conscious sedation TAVR will be the standard of  Could conscious sedation also be effective lifesaving procedure. Conscious sedation, with its ability to maximize the ease of recovcare. Most of all, I hope that this innovation for mitral valve replacement or heart ery from our procedures, is a huge advancewill lead to more patients receiving the lifevalve problems other than stenosis? ment for the thousands of patients afflicted saving care they deserve. Mitral valve replacement is most commonly with aortic stenosis in Minnesota. performed now with open surgery, but

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Targeted temperature management from cover

It is clear from animal experiments and clinical experience that even brief interruptions of cerebral blood flow or severe insults such as trauma that damage cells and disrupt normal metabolism can cause significant neurological/functional injury or even death. The potential benefit of hypothermia for the protection of CNS tissue from injury has been known for a long period of time, has been demonstrated in animal models, and is often expounded in the lay press. Although rare, it is also not uncommon in northern climates to find reports of individuals who have experienced a prolonged hypothermic cardiac arrest being revived with apparently minimal functional deficits. The benefit of therapeutic hypothermia (TH) may be secondary to the approximate 5

percent graded reduction in the rate of cerebral metabolism that occurs for every degree Celsius that body temperature is lowered (a body temperature of 32º C would correspond to a 25 percent reduction in CNS metabolism). This change in the overall metabolic demand of the CNS

The use of therapeutic hypothermia has therefore drawn

Even brief interruptions of cerebral blood flow … can cause significant neurological/functional injury or even death.

may cause a decrease in the release of excitotoxic neurotransmitters such as glutamine and inflammatory cytokines that trigger cellular apoptosis allowing the injured tissue to recover. This benefit must be balanced with other physiologic effects

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that occur such as: decreased immune response secondary to the inhibition of phagocytosis, electrolyte abnormalities, cardiac dysrhythmias, and coagulopathy that may cause adverse patient outcomes.

MINNESOTA PHYSICIAN JUNE 2016

intense interest as a potential intervention in the acute setting that may improve outcomes in patients experiencing events such as coma after cardiac arrest (CA), ischemic and hemorrhagic stroke, severe traumatic brain injury (TBI), and spinal cord injury (SCI). Hypothermia after cardiac arrest Based on 2015 statistics, the death rate for emergency medical system treated out-of- hospital CAs is approximately 90 percent for all rhythms and 70 percent for bystander witnessed shockable rhythms. For those who are comatose after spontaneous return of circulation (SROC), survival to hospital discharge with any first recorded rhythm is approximately 11 percent and survival with good neurologic function is approximately 8 percent. In 2002, two clinical trials were published in the New England Journal of Medicine demonstrating a clinical benefit to moderate TH in adult patients who were comatose after an out-of-hospital CA with ventricular fibrillation (VF) as the presenting rhythm and SROC. The study by Dr. Stephen A. Bernard and coauthors, assigned 77 patients to one of two treatment arms, either cooling to 33º C within two hours of SROC or normothermia. The study demonstrated 49

percent good outcomes in the TH cohort (defined as discharge to home or a rehab facility) versus 26 percent in the normothermia cohort. The second larger study published by the Hypothermia After Cardiac Arrest Group compared 136 patients randomly assigned to either cooling between 32º to 34º C within two hours of SROC or normothermia. This study demonstrated 55 percent favorable outcomes (defined as either good recovery or moderate disability) in the TH cohort versus 39 percent in the normothermia cohort. On the basis of these studies, as well as several case control series, the American Heart Association (AHA) issued an advisory statement in 2003 recommending that adult patients who are comatose after an out-of-hospital CA with VF as the presenting rhythm and SROC be cooled between 32º to 34º C for 12 to 24 hours. This recommendation was subsequently added to the 2005 AHA Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Despite the fact that no further randomized clinical trials were published between 2002 and 2009, several case control series suggested a beneficial effect with other presenting rhythms and the 2010 AHA guidelines made it a general recommendation for all comatose adult patients with out-of-hospital CA with SROC regardless of the presenting rhythm. It should be noted that despite the success of the 2002 publications, there was a startling lack of randomized clinical trials during the period from 2002 to 2009 that would have more clearly addressed significant issues such as; presenting rhythm, timing, depth, and length of cooling, and the relevance of clinical prognostic signs that were unanswered in the initial trials. Both studies have also drawn significant criticism due to lack of true randomization and fragility in the

Bernard study (patients were assigned to treatment cohorts based on the day of the week and a change in outcome of a single patient would have negated the statistical significance of the results) and the presence of untreated fever in a significant portion of the control populations of both studies which may have caused adverse outcomes. In 2013, Bernard and collaborators in Australia and Europe published a multi-center randomized control trial involving 939 patients assigned to either cooling to 33º C within six hours of SROC for 36 hours and active fever control for 72 hours post rewarming versus active temperature control at 36º C for the period of time in the control cohort. This study demonstrated no statistically significant difference in the 180 day mortality and neurological outcomes between the two cohorts. The AHA has subsequently changed the wording of the 2015 recommendations from TH to Targeted Temperature Management (TTM) with the more accurate statement: “The excellent outcomes for all patients in these trials reinforced the opinion that post-cardiac arrest patients should be treated with a care plan that includes TTM, but there is uncertainty about the optimal target temperature, how it is achieved, and for how long temperature should be controlled.” It would be a fair assessment that what the AHA has termed TTM is actually aggressive fever management using active cooling techniques to maintain a constant physiologically normal body temperature. Hypothermia after ischemic and hemorrhagic stroke Stroke kills approximately 130,000 Americans each year. There will be approximately 800,000 new strokes this year with 87 percent being ischemic and 13 percent hemorrhagic. Although the survival statistics for ischemic stroke are significantly better then hemorrhagic (approximately 80 percent versus 25 percent) both result in

significant morbidity and cost. Between 4 percent and 25 percent of stroke patients will have an increase in body temperature within the first six hours of developing symptoms and this increase in body temperature correlates with worse neurological outcomes. There have been several pharmacologic and active cooling studies that have addressed temperature management in this setting; none have demonstrated a significant change in either rate of death or functional outcome in these patient populations. There is one group of stroke patients that may benefit from TH. A small subset of acute ischemic stroke patients experience a catastrophic panhemispheric stroke from occlusion of either the internal carotid artery or proximal middle cerebral artery. If these patients are young, they are at high risk of death secondary to the development of cerebral edema and resulting brain herniation with an 85 percent rate of mortality. Small studies using historic controls have demonstrated that hypothermia to 33º C initiated within 24 hours of presentation and maintained for 48 to 72 hours may decrease the mortality rate by approximately 50 percent but has a high incidence of hospital/ventilator associated pneumonia and sepsis. Surgical decompression may be more beneficial in this setting with improved mortality, pneumonia, and sepsis rates with an increased delayed surgical complication risk associated with bone flap re-implantation. Hypothermia after traumatic brain injury Trauma remains the leading cause of death and permanent disability from age 5 through 44 years and the fourth overall for all age groups in the United States according to the most recent CDC data from 2013. Other than prevention, any intervention that would significantly improve the outcomes of these patients would be a major public health and economic boon to society. Because of this, there have been multiple trials

examining the effect of therapeutic hypothermia in the setting of TBI. The last Cochrane Report on TH in TBI published in 2009 performed an analysis of 23 trials and involved 1,614 randomized patients. The best known and most cited of these trials was published by Dr. Guy L. Clifton and coauthors in the New England Journal of Medicine in 2001. This was a multicenter randomized trial that examined 392 patients assigned to either cooling to 33º C within six hours of injury for 48 hours or normothermia. Although patients treated with TH had fewer episodes of elevated intracranial pressure (ICP), there was no statistical difference in functional outcome or death between the two cohorts. A subsequent multi-center trial was published by Dr. Clifton and coauthors in Lancet in 2011. This trial randomly assigned 232 patients to either cooling to 33º C within 2.5 hours of injury for 48 hours followed by gradual rewarming

or normothermia. The trial was terminated secondary to futility at the interim analysis. The most recent and definitive study is the Eurotherm 3235 trial published in 2015 in the New England Journal of Medicine by Dr. Peter J. D. Andrews and coauthors. This study was designed to investigate the role of TH in controlling elevated ICP and the effects on patient outcomes. A total of 387 patients were randomized to receive either a combination of TH and best medical management (including the possibility of decompressive craniectomy) after a sustained elevated ICP > 20 mmHg for > 5 min or normothermia and best medical management. The study was terminated early secondary to safety concerns that TH did not result in improved outcomes and may be causing patient harm. There were a total of 33 adverse effects in the TH cohort and only Targeted temperature management to page 38

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Changes in clinical practice from cover

A recent study by Harvard Medical School found that the number of telemedicine visits provided to Medicare beneficiaries increased by 28 percent annually from 2004 to 2013, according to JAMA. Telemedicine — whether through two-way video, web, instant messaging, smart phone apps, tablet apps, electronic data submission, or other wireless tools — will continue to increase, offering patients more opportunities to access health care without actually walking into a clinic.

people choose to receive care. In the next three to five years, the look and feel of the average clinic will be dramatically different from what it is today. As such, health care organizations are rethinking how they use space by planning more flexible, multifunctional spaces that integrate technology and new care models. The

care. Likewise, video consultation enables care providers to determine whether a patient should be seen in person. Patients can provide information about their vital statistics from remote locations, such as workplace wellness rooms equipped with automatic blood-pressure cuffs, thermometers, and video equipment.

Physicians’ workspaces are evolving to reflect a more mobile, technology-enabled workforce.

Flexible space planning Telemedicine and other telecommunications technology are already impacting clinic planning. Because brick-and-mortar clinics take time to build, technology often changes before a new clinic is completed. This means that the physical building is playing catch-up with the evolving technology and how

growth in electronic triage and assessment services, for instance, leads to spaces that facilitate the work of telephone triage nurses, who answer health-related questions via the phone, assess the level and urgency of treatment a patient requires, and recommend where and when a patient should seek

As clinics shift toward completing basic assessment, diagnostic, and triage tasks virtually, facility owners are now integrating spaces for new staff positions, such as health educators, patient care coordinators, telephone triage nurses, and health care information management professionals.

Desktop computers and tablets have already changed space planning, as patients check in themselves, access their records, and navigate through a clinic. The registration desk itself is shrinking, and people are becoming more accustomed to using technology, whether at kiosks or with tablets, as they move through a clinic. Additionally, health care organizations have relaunched web sites and portals that help patients assess their symptoms, obtain self-care information, and download lab results. Online tools such as MyChart enable patients to review their electronic lab results 24/7, schedule appointments, renew prescriptions, and pay bills. This remote convenience reduces required space for scheduling, check-in, and check-out functions in clinics. Furthermore, the adoption of electronic medical records (EMR) and electronic health records (EHR) as mandated

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by the American Recovery and Reinvestment Act of 2009 reduces the need for paper file storage and makes it easier for physicians, specialists, and organizations to share patient information securely. Exam rooms Technology certainly has made it into the exam room, as well. Even before getting to a clinic, many patients complete research online in order to ask informed questions with the physician, who often sits sideby-side with a patient to review medical records and educational information on a desktop or wall-mounted computer. When needed, docking stations allow mobile devices and laptops to connect to the clinic network or to a large-screen monitor. Furniture configuration and layout should seamlessly integrate the technology into the exam room to accommodate one-on-one physician/ patient consultation or family/ patient consultation.

Even with new and improved technology changing clinic planning, the exam room certainly is not going away anytime soon as it continues to serve necessary one-on-one consultation between patient and physician. But the number of exam rooms in an average clinic may decrease as patients have more opportunities to conduct basic tests and transmit health data remotely.

toward the center of the suite, with exam rooms, group exam rooms, private consultation rooms, and specialty spaces along the periphery.

toward less space, the traditional physicians’ office has evolved from a private space to an open and flexible workspace that focuses on collaboration and shared resources between caregivers. As with corporate settings, today’s clinic may bypass privately assigned workspaces for hoteling spaces or free addresses that doctors use as needed for the day. A physician splitting time between

A new clinic paradigm Traditional clinics now have the opportunity to rethink their spaces and how people use them since much of the diagnostic and communications can occur off-site. A new primary care rural health clinic in southern California, for instance, includes additional unprogrammed space that will enable the health care provider to fulfill the commitment to care for the whole person, through wellness programs, preventive care, education, community outreach, or other options — all enhanced through technology that can be integrated into the flexible unprogrammed space. The patient-centric,

Video consultation enables care providers to determine whether a patient should be seen in person.

Physician workspaces As with corporate workspaces, physicians’ workspaces are evolving to reflect a more mobile, technology-enabled workforce. With the movement

several clinics may touch down at an open-plan dictation station to update patient files after an exam. A typical clinic module may group physician and administrative workspaces

Changes in clinical practice to page 36

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PROFESSIONAL UPDATE: RHEUMATOLOGY

40-year-old woman presents to your clinic with symptoms of fatigue and generalized pain. This discomfort has lasted for two years and recently caused the patient to quit her job as a successful businesswoman. After visiting several providers—including a rheumatologist—she received a diagnosis of chronic pain and fibromyalgia. But, she’s skeptical of the diagnosis and is now seeking a second opinion. After questioning her, you learn that her worst pain is a constant, burning sensation over her trunk and feet made worse by short periods of electric shock-like pain. The pain gets worse at night. She even wears socks to avoid contact with bed sheets because it exacerbates the pain. The patient also stopped wearing her contact lenses a year ago because her eyes were dry. Now she chews gum and carries a bottle of water all the time because her mouth is very

Seronegative Sjogren’s syndrome Looking at a difficult diagnosis By Parastoo Fazeli, MD

dry. The patient’s mother has rheumatoid arthritis, but the patient’s extensive rheumatology workup was negative including a negative antinuclear antibody (ANA) test (screening for connective tissue disorders) and negative rheumatoid factor (RF). She had negative Sjogren’s antibodies (anti-SSA and anti-SSB) and normal nerve conduction studies. Her exam is normal except for a very dry tongue with lots of pinprick sensations over her feet. Moreover, she does not have classic fibromyalgia tender points. But, the patient’s skin

MINNESOTA PHYSICIAN JUNE 2016

biopsy confirms the diagnosis of small fiber sensory neuropathy (SFSN) with a reduction in epidermal nerve fiber density (ENFD). To clarify the diagnosis, you order a salivary gland biopsy (lip biopsy). With the results showing two foci of lymphocytes (more than 50 in each focus), the condition becomes clear: seronegative Sjogren’s syndrome. What’s seronegative Sjogren’s syndrome? Sjogren’s is a systemic autoimmune disease with gradually progressive lacrimal and salivary gland dysfunction, which leads to dryness of the eyes and mouth. There are two types—primary, when a patient experiences these symptoms independent of another diagnosis (the focus of this article), or secondary, when a patient has Sjogren’s along with another rheumatologic disease like rheumatoid arthritis or lupus. According to the national arthritis data workshop, up to 4 million Americans have Sjogren’s; however 30 to 40 percent of these patients don’t have positive Sjogren’s markers (anti-SSA or anti-SSB antibodies), which makes the diagnosis of seronegative Sjogren’s a challenge. What’s more, we know the condition is nine times more common in women and occurs in about 1 percent of adult females. We don’t know what causes Sjogren’s and no geographic, racial, environmental, or ethnic risk factors have been associated with it. Certain genes may increase the risk of contracting it however.

Signs and symptoms Sjogren’s can affect the whole body. In addition to dryness of the eyes and mouth, it causes fatigue, neuropathy pain, joint pain, depression, and cognitive dysfunction. The condition can impact skin, kidneys, lungs, and the central nervous system, as well as increase the size of salivary glands and lymph nodes. Most Sjogren’s patients have serious dental complications and can even develop corneal ulcers as a result of dry eyes. Delaying diagnosis can severely alter a patient’s quality of life. Adding to the seriousness of this condition, research shows the risk of lymphoma is 44 times more common in Sjogren’s patients with a lifetime risk of up to 8 percent.

There is no “Sjogren’s pill.”

Small fiber sensory neuropathy associated with Sjogren’s is characterized by severe pain attacks that usually begin in the feet or hands, but over time could affect other regions. Some patients initially experience a more generalized whole-body pain. It might not be length dependent affecting hands or feet like diabetic neuropathy. Pain sensations may be described as stabbing, burning, tingling, itching or, like the patient in the introduction, a shock-like pain that lasts seconds. Interestingly, these patients can’t feel pain that is concentrated in a very small area such as the prick of a pin. However they have an increased sensitivity to pain in general (hyperalgia) and experience pain from stimulation that typically does not cause pain (hyperesthesia). Patients might not be able to distinguish hot from cold in affected areas. Some studies suggest that pain severity and functional impairment are greater in seronegative patients. Diagnosis of this

condition is with a skin biopsy, not a nerve conduction study (NCS) or electromyography (EMG). Inflammatory arthritis in Sjogren’s presents with pain and tenderness of the joints rather than actual joint swelling or joint deformities, which makes diagnosis a challenge especially in seronegative Sjogren’s patients. Many of these patients are incorrectly diagnosed with fibromyalgia (chronic pain and fatigue syndrome, which is not autoimmune or inflammatory), but in fact their pain is due to an inflammation of the joints and neuropathy. This causes frustration for patient and family members as some providers and family members don’t believe the pain is organ related and treat it more as a condition tied to depression or chronic pain. Diagnosis Patients with seronegative Sjogren’s don’t present with anti-SSA or anti-SSB. To complicate the diagnosis even more, other markers like ANA or rheumatoid factor (RF) might not be present either. Features such as high inflammation markers (sed rate or CRP), a low white count, low complements C3/C4, cryoglobulin, and high immunoglobulins might or might not be present. Patients with dry eyes could have a positive Schirmer test (the inability to make enough tears), but minor salivary gland biopsy or lip biopsy is the gold standard for diagnosis and can be done as an outpatient procedure. Finding just one focus of > 50 lymphocytes is enough to diagnosis Sjogren’s (85 percent sensitivity and 94 percent specificity). EMG and NCSs often are normal in pure small fiber sensory neuropathy (SFSN). A punch skin biopsy shows a reduced number of intradermal nerve fiber density (ENFD) in patients with small fiber neuropathy (92 percent sensitivity, 90 percent specificity).

Management There is no “Sjogren’s pill” to treat all the Sjogren’s symptoms. We treat inflammatory arthritis of Sjogren’s like rheumatoid arthritis or lupus arthritis with anti-inflammatory drugs like NSAIDs (i.e.,

levels should be measured and corrected to at least 40 ng/ml. Management of a patient with Sjogren’s syndrome is a team effort involving an ophthalmologist, dentist, neurologist, and rheumatologist.

The condition is nine times more common in women.

ibuprofen), low-dose prednisone, or disease modifying anti-rheumatic drugs (DMARD) like hydroxychloroquine. Some patients don’t respond or tolerate these medications and need to try different medications. Rituximab (a biologic drug) has been studied in patients with Sjogren’s with mixed results (no significant improvement of fatigue or dryness in most studies). We treat dryness of the eyes with over-the-counter artificial tears (preservative free if used more than four times a day), and in severe cases with cyclosporine eye drops or punctal occlusion. For dryness of the mouth, there are several over-the-counter products like sugar free gums, lozenges containing artificial saliva, and in severe cases medications like cevimeline and pilocarpine. Good dental care with frequent use of fluoridated toothpaste and mouthwash, dental flossing along with regular professional dental attention is advised. Increasing fluid and omega-3 free fatty acid intake, reducing caffeine, and avoiding smoking helps. Regular low-impact aerobic exercise (walking three times a week) along with sleep improvement could help with fatigue. Neuropathy pain could be managed with drugs like gabapentin or pregabalin. IVIG (Intravenous Immunoglobulin) might be beneficial for small fiber neuropathy. Low levels of vitamin D are associated with neuropathy and lymphoma among patients with Sjogren’s syndrome and vitamin D

Conclusion Seronegative Sjogren’s syndrome exists and is a real rheumatologic disorder that can cause disabling symptoms of dryness, fatigue, joint pain, and neuropathy pain. It is difficult to diagnose Sjogren’s syndrome without serologic evidence of autoimmunity (i.e., positive ANA, RF, anti-SSA, or antiSSB). It’s important to keep the diagnosis of seronegative

Sjogren’s in differential when evaluating a patient with such symptoms. A proper diagnosis helps the patient and other providers to address symptoms and complaints properly. Although patients with seronegative Sjogren’s could develop fibromyalgia (chronic pain) over time, they could have pain due to inflammatory arthritis or small fiber neuropathy. This could be helped with certain medications that are not typically used for fibromyalgia pain (like steroid, hydroxychloroquine, methotrexate, or IVIG). An appropriate diagnosis helps patients understand what to expect if they have Sjogren’s and that they should be watched for signs of lymphoma. Parastoo Fazeli, MD, is assistant

professor of medicine in the division of rheumatology at the University of Minnesota and director of the Lupus Clinic. She is board-certified in medicine and rheumatology.

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RADIOLOGY

ung cancer is the leading cause of cancer death for both men and women, not only in the United States, but worldwide. The American Cancer Society estimates that 224,390 new diagnoses of lung cancer will be made in 2016 in the U.S. This includes approximately 117,920 new diagnoses in men and about 106,470 in women. They estimate that 158,080 persons will die of lung cancer this year. Lung cancer accounts for 27 percent of all cancer-related deaths. Smoking is by far the leading risk factor for lung cancer as approximately 80 percent of lung cancer deaths are thought to result from smoking. Over the last four decades there has been minimal improvement in the lung cancer mortality reduction from clinical interventions (Siegel, Naishadham, & Jemal, 2013). Often at the time of diagnosis, lung cancer is already at an advanced stage, with a five-year survival rate of approximately 17.4 percent

Lung cancer screening Understanding the fundamentals By Aaron Binstock, MD

(Surveillance Epidemiology and End Results Stat Fact Sheets: Lung and Bronchus Cancer, 2015). In light of the well-known risk factors for lung cancer, and the better prognosis with increased survival when caught and treated early, screening high-risk individuals for lung cancer has been studied in the past on multiple occasions without a clearly-defined benefit. This was largely due to limitations in CT technology for radiation dose reduction at that time and the low sensitivity and specificity of the chest X-ray (CXR) as a screening tool.

MINNESOTA PHYSICIAN JUNE 2016

The history of screening According to the American Cancer Society, lung cancer along with colon, breast, and prostate are the four leading causes of cancer death for both men and women in the U.S. and worldwide. Of these, lung cancer is the only one not subject to routine screening. Several studies have assessed ways to screen the at-risk population for lung cancer using various methods including CXR, sputum analysis, and lowdose computed tomography (LDCT). Prior studies using CXR and sputum analysis at varying intervals of time were not successful in reducing lung cancer- specific mortality (National Lung Screening Trial research [NLST]; and American College of Radiology [ACR] Lung Imaging Reporting and Data System). This is largely because a CXR typically does not detect early cancer (stage 1 and 2). The majority of lung cancer detected with CXR is stage 3 and 4, which have dismal prognoses. With the advancement of imaging technology, LDCT has become more promising. The National Lung Screening Trial, a study of over 53,000 patients, found a reduction in lung cancer mortality in highrisk patients aged 55 to 74 after being screened with LDCT compared with CXR. These individuals were enrolled and randomly assigned to three annual screens with either LDCT or CXR. The persons enrolled were considered high risk if they had a 30 pack-year history of cigarette smoking. Former smokers could also be enrolled, but they had to have quit in the past 15 years. The results showed a reduction of mortality of 20 percent in patients screened

with LDCT (ACR Lung Imaging Reporting and Data System). Since the release of the NLST results in 2011, at least 38 key stakeholder major medical societies and organizations have endorsed LDCT for the early detection of lung cancer. The U.S. Preventive Services Task Force (USPSTF) is an independent panel of non-Federal experts in preventive and evidence-based medicine. They have endorsed LDCT and recommend annual LDCT screening for people 55 to 80 years of age who have a >30 pack-year smoking history, and currently smoke, or have quit within the past 15 years. As a result of these recommendations, most people considered to be at high risk who have insurance coverage, including Medicare, will be covered for screening with no copay.

Lung cancer accounts for 27 percent of all cancer-related deaths. A screening program A successful lung cancer screening program requires a coordinated approach with multispecialty provider involvement. A provider order is recommended for the screening LDCT. After performing a risk assessment and confirming that the patient is a candidate for lung cancer screening based on the listed criteria, the most important component of a screening program begins with patient education. Shared decision making The shared decision-making process should provide clear information to the patient of the risks and benefits of the screening process in a language appropriate to the candidate. The elements to be discussed during this visit with a health care provider should include the benefits and risks of screening, diagnostic testing, over- diagnosis, the false-positive rate, and total radiation exposure. With any screening test, there is a risk of a false positive or false negative exam. This can

lead to additional imaging or unnecessary procedures, which have risks associated with them. Although low, the risks are real and the candidate for screening needs to be informed and willing to proceed. These risks can also be mitigated by having the scans reviewed by a multidisciplinary program prior to any action. The overall goal of the lung cancer screening program is to monitor and catch cancer at the earliest possible stage. It is important that the patient understands the commitment to annual screening, similar to mammography. Furthermore, it must be clearly explained that a single normal screening CT is not a green light to continue smoking and forgo further annual screening, as this will not result in improved cancer detection or survival. Patient selection/screening criteria An ideal candidate for lung cancer screening using LDCT is between the ages of 55 and 80, and who has a >30 pack-year smoking history, and currently smokes, or has quit within the past 15 years (see the sidebar). The patient must be asymptomatic, without active signs of lung cancer such as hemoptysis. An appropriate screening candidate also should not have a history of any cancer that has been treated in the last five years. Another very important part of patient selection is that the individual must be both medically able and willing to be treated for lung cancer if it is found. Part of the shared decision-making process should include counseling on smoking cessation or referral to a smoking cessation program. Once the patient verbalizes understanding, and has agreed to enter the program, the next step is the actual exam. CT examination information The exam is a low-dose CT that can be performed as an outpatient with no preparation, fasting, or IV contrast. The exam takes less than 10 minutes to complete and is performed with the lowest radiation dose possible to still detect pulmonary lesions. This is typically less

than 25 percent of the dose for a traditional diagnostic chest CT. The patient will receive less than a 3mSv radiation dose, which is less than the background radiation an individual Minnesotan is subjected to every year.

will likely see changes in the screening parameters and reporting to maximize the impact on those individuals at the greatest risk.

The ultimate goal of the lung screening program is twofold. This first is to detect cancer at an earlier and more treatable stage resulting in a decrease in the mortality rate. The second is to educate and encourage smoking cessation, which over

Low-dose CT screening can significantly reduce mortality and morbidity. After the exam, a formal report of the findings will go to the ordering provider. Similar to mammography, structured reporting will be used based on the ACR Lung Imaging Reporting and Data System (LungRADS). This results in a consistent style of reporting as well as specific criteria in nodule characterization and management recommendations. The ACR Lung-RADS should increase the cost-effectiveness of CT lung screening by secondarily decreasing the number of interval scans recommended and performed. The patient would also receive a letter reviewing the findings and recommendations. The patient should be entered into a database so they can be followed and contacted for the yearly screening exam, or before if there are abnormal findings. This information, including patient demographics and radiation dose of CT scan, would be uploaded to a national database coordinated through the ACR and Centers for Medicare & Medicaid Services (CMS). This data will be reviewed and assessed if the screening programs adhere to the guidelines, along with the impact it has on the diagnosis rate and stage of cancer. Summary Evidence-based medicine has demonstrated that low-dose CT screening can significantly reduce mortality and morbidity associated with lung cancer in high-risk patients. Lung cancer screening using LDCT within an organized program in the appropriate high-risk patient population should result in more benefit than harm.

time will have an even greater impact on reducing lung cancer rates. Currently, the screening criteria may inadvertently exclude individuals who may be at increased risk for developing lung cancer. Examples include: persons younger or older than the listed criteria, people who quit smoking longer than 15 years ago, or have had exposure to other elements that increase their risk of developing lung cancer. LDCT lung cancer screening is still in its infancy and as the data is studied, we

Aaron Binstock, MD, is director of oncology imaging at Suburban Imaging–North and past president of Suburban Radiologic Consultants– North Group. He is a board-certified radiologist subspecializing in body imaging. Dr. Binstock has been instrumental in shaping lung screening programs across the metro, as well as educating clinicians about CT lung cancer screening.

Annual CT lung cancer screening criteria • Men or women between the ages of 55–80* • Current smoker or quit within the last 15 years • Smoking history of 30 pack-years or more

[#of packs/day (x) #of years as a smoker = Pack year]

*Medicare covers ages 55–77

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SPECIAL FOCUS: MEDICAL FACILITY DESIGN

s health care evolves toward more collaborative practices and teambased patient care models, the need for dedicated team space has emerged. Merely placing people in a room and expecting them to work well together misses the point of team-based care and will inevitably fail. Successful team spaces are designed after considering the size of a team, the types of roles involved, the work being done in the space, and the goal of collaboration for patient care. Design concerns As a designer at the Mayo Clinic Center for Innovation (CFI) with a background in both architecture and service design, my team members and I have developed guidelines for designing spaces that will provide a comfortable and productive team space and reflect our work on several space design projects in clinical settings. If you’re a clinical practice about to develop an effective

Designing clinical team spaces Promoting productivity and collaboration By Allison Matthews, MArch

team space, here’s a foundation for having productive conversations with those you engage to design and build your space. Prior to any design work, the practice needs to clearly articulate how the practice works (both now and in the future) including: team makeup, individual roles, and why a team space will benefit patient care. Team makeup Our experience has shown that multidisciplinary teams benefit most from working in a collaborative space. It is important for both the team and the designer to have a clear definition of the roles and

responsibilities of everyone on a particular team. While we find that all clinical team members benefit from being in a team space, those who frequently need answers or advice from other team members tend to find the greatest benefit (e.g., nurses, schedulers, secretaries). Team size Observations and experimentation with care teams has demonstrated that teams with six to eight individuals tend to function best. Specific practice needs may require a slightly smaller or larger team. If you anticipate extremely large team sizes, consider subdividing members by equally dispersing roles on each team. While more than one team may function in the same space, design it so individuals frequently interact with eight or fewer people during the majority of their time in the team zone. Keeping pods of people, even in large spaces, on the smaller size will reduce noise and foster a greater sense of cooperation and congeniality. Ergonomics and convenience Consider sit-to-stand desks to accommodate individual preferences and standing height desks for those who are in and out of the space frequently. Sit-to-stand desks offer team members flexibility in how they work during the day and can promote wellness. Solo vs. collaborative work Team spaces must support both collaborative work and heads down, solo work at various times during the work day. For instance, equipping the space with sit-to-stand desks allows team members to indicate their availability for interaction through their posture: teams

MINNESOTA PHYSICIAN JUNE 2016

can then develop a signaling system for each other such as standing means “come talk to me” and sitting means “I need this time to work alone.” Situational awareness Often on teams, one person functions as an “air traffic controller.” This individual may be a nurse, physician, or scheduler—this will vary depending on your practice. This role typically knows where each team member is, both physically and in terms of progress on the episode of care, to ensure an overall understanding of what is necessary to successfully complete the team’s work. Providing this team member with the best sight lines to the team and activity outside of the team room makes the entire team more efficient. Special considerations for education Learners are often present in team rooms: residents, fellows, medical students, nursing students, etc. They use their time in the team room to discuss cases, ask questions, and learn through osmosis. Simple adjustments, such as double workstations for collaboration, room for two people to share a computer monitor, and conversation tables with a large whiteboard, improve the learning experience while not taking away from the team environment. Noise is everyone’s biggest fear Inevitably, when a group embarks on team space planning, noise levels emerge as a major concern. Initially, people anticipate that phone conversations, dictation, and group discussions will make the space too noisy to function. While team spaces are always noisier than private offices, noise is dealt with in a way that accommodates almost any team dynamic. Certain activities at peak times, such as dictation, may be best dealt with by providing a dictation room. Installing acoustic panels on wall surfaces; clustering activity types; creating small booths for dictation; and providing pink noise, acoustic partitions, and

headsets dramatically reduce noise levels. Creating separate work environments When work space partitions are necessary, take care to use partitions less than 53 inches in height (for certain groups, lower may be preferable) within an individual team pod. These shorter partitions provide adequate sound mitigation, while maintaining sightlines to promote collaboration. Use 67inch partitions if it’s necessary to separate two team areas. Non-space related factors for using a space Often what defines how a team uses a space is not the space itself but other factors. Before final space layout decisions are made, consider: 1) log-in time for workstations (long lag times may make it difficult to share workstations), 2) shared equipment needs (will staff periodically need bulky equipment?), 3) use of room occupancy monitoring systems

or communication technologies to connect with those outside of the team space. General process considerations of each practice

cabinets with magnets; and use more color in the space to avoid overwhelming neutral tones.

Multidisciplinary teams benefit most from working in a collaborative space.

should be considered in the overall design. Individual concerns Some team spaces call for shared/flexible workstations instead of dedicated desks. This makes personalization of the work space more challenging but not impossible. Strategies to celebrate individual team members in a shared space include large cork boards with rotating themes (January: post a photo of your vacation, February: post a photo of your pet, March: post your favorite quote, etc.); decorate file

Where should I put my stuff? People come with stuff. In winter, it’s coats and boots and in summer it’s umbrellas and raincoats. Everyone has technology that needs charging: laptops, cell phones, and tablets. Making space for people to store their things is essential to the success of a team space. Without a clear landing spot for these personal items, the space will be cluttered and lose functionality. Dedicated filing cabinets for an individual’s paperwork and personal items; small lockers to protect

valuables; drawers equipped with power for charging; hooks for coats and umbrellas; and rolling filing cabinets can create flexible storage solutions for each team member. What will happen to my office? The hottest of the hot-button issues is getting rid of offices to accommodate a team space. While we often hear “I need an office,” when we probe more deeply, we find the needs leading to that assumption can be accommodated with multiple solutions, often better for team dynamics. We hear various reasons to justify offices: a need for quiet space, a place to put up personal items such as diplomas and family photos, a need to have confidential patient conversations, and a personal preference to work alone. While offices are the best solution for some teams, we strongly encourage teams to look closely at alternatives that provide shared private spaces Designing clinical team spaces to page 34

JUNE 2016 MINNESOTA PHYSICIAN

2016 health care architecture

HONOR ROLL

innesota Physician’s 2016 Health Care Architecture Honor Roll recognizes 11 outstanding projects. This year’s Honor Roll projects include new or renovated clinics, emergency departments, surgery centers, hospitals, a therapy clinic, and a birth center in urban, suburban, and Greater Minnesota. The medical services range from routine clinic visits to specialized care. Populations served include the standard roster of patients seen at outpatient clinics and hospitals as well as specialized groups — such as children, adolescents, and mothers. Although the facilities differ in intended use and population served, they share a focus on providing a healing environment, efficient design and floor plans, and natural materials. Many projects incorporated the onstage/offstage operational model to separate patient areas from staff areas. A child psychiatric hospital worked to break down barriers between patients and staff through design and a children’s therapy center built a bright and inviting super gym large enough to accommodate multiple therapy sessions at once. Minnesota Physician Publishing thanks all those who participated in the 2016 Honor Roll.

MINNESOTA PHYSICIAN JUNE 2016

Fairview Southdale Hospital Carl N. Platou Emergency Center Type of facility: Emergency department

Contractor: Knutson Construction Services

Location: Edina

Completion date: October 2015

Client: Fairview Health Services

Total cost: $35 million

Architect/Interior design: HGA Architects and Engineers

Square feet: 80,715

Engineer: HGA Architects and Engineers (civil); Dunham (mechanical, electrical, plumbing)

Facing page: Main entrance (top) and color-shift panels (bottom) Top: Waiting area

Allina Health Regina Hospital Emergency Department Type of facility: Emergency department Location: Hastings Client: Allina Health Architect/Interior design: HGA Architects and Engineers Engineer: HGA Architects and Engineers Contractor: Kraus-Anderson Construction Company Completion date: December 2015

he new Emergency Center at Fairview Southdale Hospital creates a strong public presence with the use of striking forms and materials. The sculptural screened glass feature wall provides privacy while admitting natural light into public spaces; at night, backlighting transforms the glass into a beacon visible to the community. The curved cantilevered second floor is clad in color-shift metal panels that change color with the viewing angle. To enhance the emergency department (ED) patient experience, the design incorporates an innovative on-

stage / offstage concept that separates patient areas from busy staff areas. The result is a calming and quiet patient zone, and a collaborative staff area. The Emergency Center has 43 treatment spaces including intake and urgent care rooms, a trauma room, two resuscitation rooms, and five behavioral health spaces. A new 18-bed observation unit on the second floor creates a quiet place for patients needing further observation, while increasing the efficiency of the ED. Modular exam and triage rooms can be opened or closed to accommodate changing needs.

egina Hospital’s new addition expanded their emergency services and imaging departments. The new emergency department was designed around an onstage/offstage operational model that separates patient care areas from care team and staff areas. This affords more privacy and centers the staff core in the middle of the department. Treatment rooms have two means of access; one from the staff core and the other from the semi-public corridor ringing the department. The addition includes a two-stall ambulance garage, two trauma bays, and eight treatment rooms. Two treatment rooms can be used as observation rooms if the need arises. The outpatient surgery entrance was relocated and connects into the main public circulation of the hospital, with wayfinding for patients and visitors inherent in the design. The renovated imaging department includes room for a new CT scanner and a dedicated MRI machine.

Total cost: $7.5 million (construction cost) Square feet: 16,170

Top right: Staff work core Bottom: Entrance JUNE 2016 MINNESOTA PHYSICIAN

HEALTH CARE ARCHITECTURE Indian Health Services Clinic Type of facility: Clinic

Contractor: Nor-Son

Location: Cass Lake

Completion date: December 2015

Client: Cass Lake–Indian Health Services

Total cost: $12,733,000

Architect/Interior design: EAPC Architects Engineers

Square feet: 8,180 sq. feet of renovated space; 26,212 sq. feet of new construction

Engineer: EAPC Architects Engineers (mechanical, electrical, structural); Northern Engineering and Consulting, Inc. (civil)

eeding more space, the Indian Health Services Clinic renovated their existing clinic and built a new addition. Because it was such a major project, the construction was done in phases to avoid disrupting patient services and care. The architects designed the building with many LEED standards in mind such as light pollution reduction, water efficient landscaping, optimized

energy performance, and enhanced indoor air quality. New clinic space includes treatment rooms, exam rooms, consult rooms, a behavioral health area, and staff space. The design follows an onstage/offstage model that involves a secure separation of staff and patient areas, while keeping patient travel distances to a minimum. Many areas of the existing clinic were expanded or relocated and the ventilation system and other mechanical components were replaced. A covered main entrance was added along with a new lobby.

Top: Waiting area Bottom: Building exterior

St. Luke’s Surgical & Procedural Care Center Type of facility: Surgery center

Contractor: ERDMAN

Location: Duluth

Completion date: July 2015

Client: St. Luke’s

Total cost: $9,837,575

Architect/Interior design: ERDMAN

Square feet: 35,000

Engineer: ERDMAN

Left top: Hybrid operating room Left bottom: Building exterior Right: Reception desk

MINNESOTA PHYSICIAN JUNE 2016

welve months of planning and research by the hospital and the architects ensured that the St. Luke’s Surgical & Procedural Care Center was designed with the patient experience in mind. This cutting edge expansion was designed to allow for growth as St. Luke’s business needs change. The facility includes a highly sophisticated, technologically advanced surgical care center with 42 private pre-op and post-op patient rooms that allow family to be with the patient before and after surgery, bedside registration, four universal operating rooms, one special procedures room, four endoscopy rooms, and a coffee shop. A hybrid operating room lets specialists work as a team on the most complex cases, providing critically ill and severely injured patients with all services in one place, reducing the risk of complications when transporting patients. A skybridge connects the expansion to the hospital.

HONOR ROLL 2016 HealthPartners Bloomington Clinic Type of facility: Outpatient multi-specialty clinic Location: Bloomington Client: HealthPartners Architect/Interior design: Mohagen Hansen Architecture | Interiors Contractor: Greiner Construction Completion date: November 2015 Total cost: $3,300,000 Square feet: 36,250

Right: Reception Bottom left: Waiting area

n order to keep the Bloomington Clinic completely operational during its renovation, the project required two major phases of construction that were then broken down into 10 smaller phases. The clinic underwent a major interior renovation in order to create a more efficient and aesthetically pleasing environment for patients of all ages. In order to make an immediate impression, the entry and reception desk

were redesigned to be welcoming and comfortable. Colorful artwork hung throughout the building, even in blood draw bays, was key to providing a relaxing environment for patients. Coordination with the artwork and furniture vendors in the design documents ensured easy and speedy installation during the construction process. The project also included minor modifications to the exterior of the clinic with new windows and paint.

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HEALTH CARE ARCHITECTURE Children’s Hospital St. Paul Type of facility: Hospital entrance building Location: St. Paul Client: Children’s Minnesota Architect/Interior design: HDR Engineer: Paulson & Clark Engineering Contractor: McGough Construction Completion date: May 2015 Total cost: $5 million Square feet: 3,000

or years, Children’s Hospital in St. Paul lacked an eye-catching main entrance, but the new iconic entry addition captures the imagination with sculptural ribbons that draw you in. A central garden complete with sculptures and stars makes you want to linger before entering the hospital. Abundant light shining through the two- story atrium along with bright-colored stars highlight the vibrant space and add a bit of dazzle when you arrive. It was important that the space feel whimsical and childlike

and not look imposing. At night, the entrance tower is a well-lit beacon that invites visitors in. A creative welcome center is strategically positioned at the intersection of the Children’s Patient Tower and the United Hospital Baby Center. Star patterns on the floor guide patients and visitors to the appropriate elevator and cutouts within the floor Top left: Main entrance create creative and Right: Entry interior intriguing scenes.

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HONOR ROLL 2016 The Mother Baby Center at Mercy Hospital Type of facility: Birth center Location: Coon Rapids Client: Allina Health and Children’s Minnesota Architect/Interior design: HDR Engineer: Loucks; Dunham Contractor: Knutson Construction Services Completion date: July 2015

Top: Building exterior Middle: Entrance overhang Bottom: Corridor

Total cost: $28 million Square feet: 62,000

he Mother Baby Center at Mercy Hospital sits on the edge of the Mississippi River, so the owners and architects took inspiration from the river as the central theme of the addition. A color scheme was chosen that was fluid and soft, and textural elements such as stone and wood accentuated the theme. Photos of river images used in rooms and hallways encourage peace, tranquility, and healing. Iconic design elements from the first Mother Baby Center in Min-

neapolis, such as super graphics, sculptural ribbons, lighting, and an iconic exterior are carried through the Mercy Hospital center as well. The new facility includes triage rooms, labor and delivery rooms, post-partum rooms, a special care nursery, and an operating room suite, which ensures that mothers receive state-of-the-art labor, delivery, and post-partum care.

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HEALTH CARE ARCHITECTURE PrairieCare Child Psychiatric Hospital Type of facility: Inpatient child and adolescent mental health hospital

(mechanical); Clark Engineering (civil/structural); Voson (plumbing)

Location: Brooklyn Park

Contractor: R.J. Ryan Construction, Inc.

Client: PrairieCare

Completion date: August 2015

Architect/Interior design: Pope Architects

Total cost: $24.5 million

Engineer: Egan Company (electrical); Legacy

Square feet: 72,588

Top: Lobby Bottom: Main entrance

n filling Minnesotaâ&#x20AC;&#x2122;s void of specialized psychiatric services for children and adolescents, PrairieCareâ&#x20AC;&#x2122;s vision was to transform psychiatric care through design. The new 50-bed Child Psychiatric Hospital offers a safe and supportive healing environment and breaks down barriers between patients and staff. The design goal was to create a highly secure setting that is non-institutional and tailored to its population. This was accomplished through non-obtrusive security features, innovative building materials, vibrant finishes, and access to nature. Blending wood and stone at the entry brings to mind a north woods destination and evokes a healing environment. Patient care stations, day rooms, and therapy spaces act as the heart of the building, connecting staff and patients and encouraging active healing. Fun colors and open doorways invite children in to play, explore, and become comfortable in their surroundings.

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HONOR ROLL 2016 Sanford Moorhead Clinic Type of facility: Ambulatory care center Location: Moorhead Client: Sanford Health Architect/Interior design: JLG Architects Engineer: Obermiller Nelson Engineering (mechanical, electrical, plumbing); Heyer Engineering (structural); Ulteig Engineering (civil) Contractor: JE Dunn Construction Completion date: April 2014 Total cost: $11,200,000 Square feet: 49,250

Top: Building exterior Middle: Offstage staff area Bottom: Lobby

ith an eye to reimagining health care delivery for the 21st century, Sanford Health built the new state-of-the-art Moorhead Clinic. They ended up creating a completely new prototype for their clinical model moving forward. The clinic follows a collaborative, onstage/offstage care delivery model that separates patient and provider areas making clinic visits more efficient for providers and less time consuming for patients. Efficient floor plans eliminate wasted steps and staff areas are open to promote collaboration. The project includes 48 exam rooms capable of being organized into separate, flexible neighborhoods that each contain a procedure room and staff work area. Patient corridors are filled with daylight, and color-coded carpet tiles and bulkheads aid wayfinding. A large diagnostic wing is dedicated to laboratory space, a radiology suite, an occupational medicine department, and a large pharmacy.

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HEALTH CARE ARCHITECTURE St. David’s Center Pediatric Therapy Clinic – “Mara’s Wing” Type of facility: Therapy clinic Location: Minnetonka Client: St. David’s Center for Child & Family Development Architect/Interior design: Pope Architects Engineer: Westwood (civil); Outworks (landscape); Clark Engineering (structural); Gilbert (mechanical); Collins (electrical)

t. David’s new, state-of-the-art Pediatric Therapy Clinic, named “Mara’s Wing” in honor of Mara Bennett, centralizes their occupational and speech therapy services and promotes staff collaboration. The clinic’s design enhances the therapists’ ability to intervene as early as possible and provide critically needed services. It features four speech Top: Super gym Bottom: Reception therapy rooms, a and main lobby music therapy room, a feeding treatment room and kitchen,

Contractor: McGough Construction Completion date: April 2016 Total cost: $6.7 million for Phase II (total project: $11.3 million) Square feet: Mara’s Wing: 7,350 (total project: 53,620 sq. feet of renovated space; 6,345 sq. feet of new construction)

five occupational therapy gyms able to schedule one to four children at a time, an Interactive Metronome room, and hallways designed to support therapy. Every treatment space features one-way observation windows that let parents and therapists observe treatment strategies. A 1,516 square foot super gym has a 19-foot ceiling with expansive windows to let in natural light and features a climbing wall and zip line. All of the gyms can be modified to meet a child’s evolving needs. A phased master plan launched construction in 2011.

Healthcare Planning and Design

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HONOR ROLL 2016 University of Minnesota Health Clinics and Surgery Center Type of facility: Clinic and outpatient surgery center

Contractor: McGough Construction

Location: Minneapolis

Completion date: February 2016

Client: University of Minnesota Health

Total cost: $165 million Square feet: 342,000

Architect/Interior design: CannonDesign

he new state-of-the-art Clinics and Surgery Center houses 37 specialties and 10 outpatient operating rooms and has been designed so complementary clinics (such as ear, nose, and throat and audiology services) are adjacent to each other for the sake of convenience. Upon entering the building, patients are greeted by a concierge with a tablet who reviews appointment information with them and gives them a real-time location-monitoring badge. The badge lets the nurse find patients without calling their name out creating a personal care experience. Exam rooms feature photographs of Minnesota landscapes, designed to reduce patient anxiety. To bolster collaboration and research, private offices have been eliminated for providers and staff. Shared and open workspaces allow teams to discuss best practices for care

delivery. “Discovery bars” located on each floor let patients use tablets to search for clinical trials.

Top left: Lobby Bottom right: Building exterior

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SPECIAL FOCUS: MEDICAL FACILITY DESIGN

ddiction treatment center patients are unique. They are often socially marginalized and stigmatized because of their addiction. Through the recovery process, they learn how to create a new life and a new world for themselves. Recovery is most successful when people feel good about themselves, when they are respected and valued. The experience at a recovery center is unique in a patient’s life. So, too, is the design of a successful treatment facility. Mike Schiks, executive director at Project Turnabout, a treatment center, elaborates, “The concept of therapeutic environment/community is critical to what we do. While it isn’t easily described, it’s about creating ‘a feel’ as much as creating a space. We wanted a place that communicates safety, respect, and hope to individuals and families who come to us for help. We need a setting conducive to people dropping their defenses, rediscovering their

Substance use disorder treatment centers Facility design can help recovery By Richard P. Engan, AIA, LEED AP, CID, and Mitra Milani Engan

value, and making changes in their lives.” While the needs of each patient — and treatment facility — are unique, there are a few design secrets that consistently improve treatment outcomes. Knowledge of these architectural best practices can help every health care leader make successful decisions when planning to build a treatment center. Minnesota roots We’ve identified best practices in treatment center design

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through 36 years of health care design experience. Our inspiration derives in part from our roots in Willmar, Minn., where the “Minnesota Model” of addiction treatment was pioneered in the 1950s. Since then, this model has been adopted and adapted around the world. Borrowing from the principles of Alcoholics Anonymous (AA), this approach provides residential treatment including lectures, open discussions, small group therapy, and peer interaction (Montvilo, 2012). The Minnesota Model Dan Anderson was a founder and primary innovator of the Minnesota Model at the Willmar State Hospital. He went on to expand and share this model during 30 years of work at the Hazelden Foundation in Center City, Minn. “The Minnesota Model represented a social reform movement that humanized the treatment of people addicted to alcohol and other drugs,” said Jerry Spicer, former Hazelden president and author of, “The Minnesota Model: The Evolution of the Multidisciplinary Approach to Addiction Recovery.” “Dan played a major role in transforming treatment wards from ‘snake pits’ into places where alcoholics and addicts could retain their dignity.” Dignity was the foundation of Anderson’s work. Dignity is also the foundation of successfully designed treatment centers. Early in our practice we were advised by Dr. Vince Mehmel, founding director of Woodland Centers’ community mental health program in

Willmar, who said, “My job is half done if a facility conveys a sense of patients feeling good about themselves and a feeling that this place is successful.” Keys to a successful recovery Smart design plays a powerful role in creating the right “feel” for a therapeutic environment. It starts with a big-picture vision and then moves through phases of focus on to greater degrees of detail. Attention to three specific design features has a particular influence on how patients feel in a treatment center: 1) scale, 2) homelike features, and 3) natural beauty. Scale Scale is an architectural term that describes both the size of spaces as well as the way spaces relate to each other. Attention to scale can have an extraordinary effect on how people feel in their physical surroundings. For example, high ceilings in a lobby can make a space feel grand and impressive, while lower ceilings can make a lobby feel more inviting and safe. Very large spaces can feel majestic but impersonal; very small spaces can feel cozy but claustrophobic. Decisions about scale need to be appropriate for the intended uses of each space and its surroundings. In treatment centers it’s important that both outdoor and indoor spaces are designed to emphasize a human, residential scale. This encourages the kind of peer-to-peer and peer-to-staff connections that lead to optimal recovery outcomes. Here are some examples of how important scale is in design: • Regardless of the total size and population of a treatment facility, patients are accommodated in residentially scaled units or “pods” of 15 to 25 residents per unit. Each of these pods shares therapeutic, social, and dining times with only their fellow pod members. This encourages bonds and camaraderie to form that lead to optimal treatment outcomes. • Group therapy rooms are designed for a maximum of

10 to 20 people. This group sizing intensifies the relationships that are important for recovery. Patients get to know members of their group very closely. • Circulation (how people move through a building) and scheduling are designed to allow each house to move between dining, activity, and recreation areas with minimal interaction with residents from other houses — this helps maintain the residential scale of the facility.

spacious, and homelike— conveying the message that patients are respected and cared for. »» Bedrooms that have low half-walls between beds maintain a sense of privacy without creating isolation.

Homelike features Thoughtful attention needs to be paid to creating a homelike environment. Many addiction treatment patients have lost their original home and have been living without the social controls that come with residing in a home. Through appropriate use of scale and finishes, a homelike, residential feeling aids with the recovery process. For example: • Patient bedrooms can be designed to be comfortable,

»» Personal pinboards are provided next to each bed so patients can hang photos of loved ones and mementos of home. These are generally comforting; they also serve as a reminder of why a resident may be working on recovery, e.g., for their children. • Double and triple occupancy bedrooms support the intention that residents should spend waking hours with others in group areas

Successful treatment centers make use of several architectural best practices.

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of the center. Living units are designed to encourage patients to spend free time working on their addiction in small groups of other residents, rather than isolating themselves in bedrooms. It’s natural for people to want

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to retreat into themselves; however, successful treatment requires that people engage with other residents and with staff. • Overall a homey, comfortable atmosphere is provided, with areas for conversation and personal reflection. This design concept allows clients to support one another in their recovery process. Natural beauty The healing effects of nature are well known. Knowledge

of the stress-relieving benefits of access to nature in health care environments dates as far back as the earliest large cities in Persia, China, and Greece (Velarde, Fry, & Tveit, “Health Effects of Viewing Landscapes,” 2007). Incorporating this knowledge into treatment center design has a significant positive effect on treatment outcomes. Calming interaction with the natural world can be provided in both interior and exterior portions of treatment centers. It’s important to include lots of windows to bring the outside in, and create pleasant spaces for small group interaction or areas for residents and their families to meet. Whenever possible, treatment centers should also provide outdoor environments for quiet, individual reflection—e.g., hiking trails, labyrinths, or benches overlooking pleasant landscapes. Substance use disorder treatment centers to page 32

Cuyuna Regional Medical Center is seeking two full-time Family Medicine physicians for its Crosby Clinic. Located in the heart of the Cuyuna Lakes Area, CRMC’s Crosby clinic has recruited 22 New and dedicated, quality physicians & APC’s in the last 2 ½ years that, along with the required up-to-date technology, have developed CRMC into a regional resource for advanced diagnostic and therapeutic healthcare services. Our Family Medicine opportunity: • MD or DO • Board Certified/Eligble in Family Medicine, Internal Medicine or IM/Peds • Full-time position equaling 36 patient contact hours per week • Work 4.5 days a week. • 1 in 11 Peds call. (Majority of calls handled by phone consultation) • Practice supported by 14 FM colleagues, APC’s and over 35 multi-specialty physicians • Subspecialty providers—Internal Medicine, OB/GYN, Orthopedics, Urology, Surgery, Oncology, Pain Management and more • Competitive comp package, generous signing bonus, relocation and full benefits • New Residients are encouraged to apply A physician-led organization, CRMC has grown by more than 40 percent in the past three years and is proudly offering some procedures that are not done elsewhere in the nation. The Medical Center’s unique brand of personalized care is characterized by a record of sustained strength and steady growth reflected by an ever-increasing range of services offered.

Contact: Todd Bymark, tbymark@cuyunamed.org (218) 546-3023 | www.cuyunamed.org JUNE 2016 MINNESOTA PHYSICIAN

Substance use disorder treatment centers from page 31

Influencing a patient’s new reality An important part of treatment is changing a patients’ sense of reality while they are in treatment. A former client and treatment center administrator phrased his goal as, “A Whole New World.” Through the design of a center’s physical environment and treatment program, the goal is to empower clients to envision and create a new way of living. Once this experience has been achieved through treatment, it’s important that patients are able to easily recall the memories of their treatment experience. This memorability helps them reintegrate into the bigger world with their newly learned skills. Several design principles — contrast, fellowship, and values — assist in building memorability and a new reality.

Contrast The treatment environment should contrast with what patients were accustomed to before checking in. The features

comfort, and security. The sense of fellowship created through family-style meals can then be carried through the rest of each day’s activities.

“We wanted a place that communicates safety, respect, and hope.” Mike Schiks described earlier (including warm, homelike settings with an emphasis on natural beauty) provide this contrast for many residents, whose reality before treatment is often less comfortable. Fellowship Serving meals in a family- style environment that promotes fellowship can have a powerful impact on patients. In contrast to an institutional feeling or eating alone in front of a TV, family-scaled dining establishes memories of friendship,

Views As described earlier, views of natural beauty are an important part of a healing environment. The views in a treatment center should be designed to be unique and memorable and will help patients remember what they learned in treatment. Conclusion Addiction is a phenomenon that has been fundamentally reframed in the past century. Through the work of pioneering professionals and dedicated

recovering addicts, the “Minnesota Model” and similar approaches have moved our culture from the vilification of addicts towards the recognition of their dignity. The most effective treatment centers are those that empower people to rediscover their dignity. Successful treatment centers make use of several architectural best practices—or “secrets”— including attention to scale, homelike features, and natural beauty. Use of these design practices results in a treatment experience that is memorable enough to propel patients into post-treatment success. Richard P. Engan, AIA, LEED AP, CID,

is principal architect and founding partner of Engan Associates Architects and Interior Designers. Founded in 1979, Engan Associates specializes in critical access health care design. Mitra Milani Engan is the communications director at Engan Associates Architects and Interior Designers.

North Memorial is hiring MDs, NPs and PA-Cs.

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 dennisd@mankatoclinic.com

Apply online at www.mankatoclinic.com

MINNESOTA PHYSICIAN JUNE 2016

He needs you.

We are a fiercely independent, physician-led organization. Our physician leaders, including our CEO, and VPs see patients every week. Healing defines us. Not bureaucracy. We treat our patients and our employees better. We’re committed to ensuring our providers have fulfilling clinical work, competitive salary and benefits, and work-life balance. Interested applicants may contact: Robert McDonald, MD Medical Director, Primary Care Robert.McDonald@NorthMemorial.com Todd Gengerke, MD Medical Director, Urgent Care and Convenient Care Medicine Todd.Gengerke@NorthMemorial.com

FAMILY PRACTICE PHYSICIANS:

What if work was where you went to recharge? Do you know what it feels like to work with a sense of purpose? At Marathon Health, we’re on a mission to put “health” back in healthcare. We have partnered with Cargill’s turkey and cooked meats business in Albert Lea, MN and are looking for a parttime Family Practice Physician to work with employees and their families (newborns +). This is an onsite position, working either four hours per week or two days per month (total:16 hours per month) with a clinical team consisting of a Family Nurse Practitioner and a Medical Assistant. There are no on-call hours. Our intention is to provide the best patient care in a collaborative clinical community, and to give access to the workforce population in and around Albert Lea. Imagine – work could be the highlight of your day. For a more detailed job description and to apply online, please visit www.marathon-health.com. MARATHON HEALTH IS AN EQUAL OPPORTUNITY EMPLOYER

St. Health Cloud VA Care System Brainerd | Montevideo | Alexandria

Opportunities for full-time and part-time staff are available in the following positions: • Associate Chief of Staff, Education

• Physician (Compensation & Pension)

• Associate Chief of Staff, Primary Care

• Physician (Pain Clinic)/Outpatient Primary Care

• Dermatologist • Internal Medicine/ Family Practice

• Psychiatrist

• Occupational Health/ Compensation & Pension Physician

Applicants must be BE/BC.

US Citizenship required or candidates must have proper authorization to work in the U.S. Physician applicants should be BE/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.

You focus on taking care of patients. We’ll take care of the rest. To learn more, visit allinahealth.org/physicianjobs.

For more information: Visit www.USAJobs.gov or contact Nola Mattson, STC.HR@VA.GOV Human Resources 4801 Veterans Drive, St. Cloud, MN 56303

(320) 255-6301 JUNE 2016 MINNESOTA PHYSICIAN

Designing clinical team spaces from page 19

available to all team members as they are needed. Our observations have demonstrated that team members benefit greatly from overhearing spontaneous conversations and are able to quickly and productively collaborate on the fly. Creating spaces, even if private, that support team members finding each other when needs arise allows for natural conversations and team building. A team space doesn’t necessarily mean that offices should be eliminated, but it also doesn’t mean that they should be maintained either. When making this decision consider: • Do the people who will be in this space have a consistent place to land each day? Staff members who frequently change their work location (rotating between specialty clinics daily) will need a separate place to call home.

• Are the staff that are frequently in the space engaged in non-clinical activities (education, research, or administration)? This often requires a dedicated work space away from the team room.

A note about confidentiality When developing plans for team spaces, we often hear a concern that people may overhear confidential patient information. In the vast majority of situations, this is less of a concern than anticipated. As

Consider sit-to-stand desks to accommodate individual preferences.

Even when offices are eliminated, several excellent (and often preferable) solutions exist to accommodate the occasional need for a private work space. Small reservable spaces that can accommodate one to two people with a door can provide space for private heads down work, sensitive conversations, and video calls.

a care team, it is appropriate for all team members to hear conversations about care. We also find that people work very professionally and will, by and large, remove themselves from or ignore conversations regarding patients whose care they are not involved in. There are notable exceptions when privacy does need to be maintained, for example, family members of

the team receiving care or even team members receiving care. Consider these exceptions in terms of frequency and operational strategies to put into place. It is also important to consider what non-team members can hear when passing by or sitting next to the team space. Conclusion Successfully designing a collaborative clinical space provides an incredible opportunity to not only think about the space itself, but how people can work together most productively. Thoughtful consideration of the experience of working together will lead to a space that is not only functional, but also leads to higher quality patient care and better staff satisfaction. Allison Matthews, MArch, is a service

designer at the Mayo Clinic Center for Innovation where she works to improve the experience and delivery of health and health care.

Olmsted Medical Center, a 220-clinician multi-specialty clinic with 10 outlying branch clinics and a 61 bed hospital, continues to experience significant growth. Olmsted Medical Center provides an excellent opportunity to practice quality medicine in a family oriented atmosphere. The Rochester community provides numerous cultural, educational, and recreational opportunities. Olmsted Medical Center offers a competitive salary and comprehensive benefit package.

Opportunities available in the following specialties: Comprehensive Ophthalmology/ Surgeon

Rochester Southeast Clinic

ENT

Hospital

General Surgery Hospital

Psychiatrist

Sleep Medicine

Psychiatrist – Child & Adolescence

Urology

Rochester Southeast Clinic

Rochester Northwest Clinic

Rochester Southeast Clinic

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 34

MINNESOTA PHYSICIAN JUNE 2016

Hospital

BEYOND TREATING, THERE’S CARING

Sioux Falls VA

Health Care System

W E L L A N D BE YO N D Fairview Health Services seeks physicians with an unwavering focus on delivering the best clinical care and a passion for providing outstanding patient experience.

We currently have opportunities in the following areas: • • • • • • • • •

Allergy/Immunology Dermatology Emergency Medicine Family Medicine General Surgery Geriatric Medicine Hospitalist Internal Medicine Med/Peds

• • • • • • • • •

Neurology OB/GYN Orthopedic Surgery Pain Medicine Palliative Care Pediatrics Psychiatry Pulmonary Medicine Urology

To learn more, visit fairview.org/physicians, call 800-842-6469 or email recruit1@ fairview.org fairview.org/physicians TTY 612- 672-7300 EEO/AA Employer

Sorry, no J1 opportunities.

PRACTICE WHERE BEAUTY SURROUNDS YOU

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. Please contact: Travis Luedke, Cook Area Health Services, Inc., 20 5th St. SE, Cook, MN 55723 tluedke@scenicrivershealth.org 218-361-3190

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 healthcare positions: Cardiologist

Orthopedic Surgeon

Endocrinologist

Physiatrist

ENT (part-time)

Psychiatrist

Emergency Medicine

Pulmonologist

Gastroenterologist

Rheumatologist (part-time)

Hospitalist

Urologist (part-time)

Oncologist

(605) 333-6852 www.siouxfalls.va.gov Apply online at www.USAJOBS.gov

Join the top ranked clinic in the Twin Cities A leading national consumer magazine recently recognized our clinic for providing the best care in the Twin Cities based on quality and cost. We are currently seeking new physician associates in the areas of:

• Family Practice • Urgent Care We are independent physicianowned and operated primary clinic with three locations in the NW Minneapolis suburbs. Working here you will be part of an award winning team with partnership opportunities in just 2 years. We offer competitive salary and benefits. Please call to learn how you can contribute to our innovative new approaches to improving health care delivery.

Please contact or email CV

Joel Sagedahl, M.D. 5700 Bottineau Blvd., Crystal, MN 55429

763-504-6600 erinp@nwfpc.com

www.NWFPC.com JUNE 2016 MINNESOTA PHYSICIAN

Changes in clinical practice from page 13

community-focused clinic also provides family space for those waiting for a relative in the exam room, and an on-stage/ off-stage physician/patient relationship in the clinic area. The on-stage/off-stage model provides separate walking paths for staff and patients and dual-entry exam rooms so patients enter from public corridors and providers enter from staff zones. Taking the concept of flexibility and adaptability a step further, many health care organizations also have an opportunity to imagine a new kind of clinic — a clinic that takes an integrated approach to health and wellness. This might be reminiscent of a retreat, in which patients spend a day in a spa-like setting for their annual physical. The day may include visits with a primary care physician and specialists for a complete checkup,

onsite wellness classes, nutrition demonstrations, lunch in a high-end cafeteria, or time in a learning center equipped with interactive, touch-screen technology and wi-fi. Patients can track their appointments and review their test results via tablets or other wireless devices supplied by the clinic.

virtual health care services, advice, and referral for patients who ordinarily might turn to an emergency room or urgent care unit for non-life-threatening conditions. Much like virtual colleges or massive open online courses (MOOC), virtual clinics serve a niche need through technology.

quality care. As more patients find more choices in their care through technology, the most successful clinics will create innovative approaches to delivering superior care through ever-evolving, ever-improving electronic telecommunications technology.

Christine Guzzo Vickery, CID, EDAC,

Many health care organizations also have an opportunity to imagine a new kind of clinic ... that takes an integrated approach to health and wellness.

Some clinics are going even further by eliminating brick and mortar altogether. MedCareLive.com, for instance, is a virtual clinic serving the California market. While not meant to replace brick-andmortar clinics, it provides

For health care providers, evolving technology offers unlimited opportunities to rethink service delivery in both a brickand-mortar and virtual world. For many health care organizations, flexibility and adaptability are essential to delivering

is senior health care interior designer at HGA Architects and Engineers. She is co-author of Modern Clinic Design: Strategies for an Era of Change, with HGA colleagues Douglas Whiteaker and Gary Nyberg. Douglas Whiteaker, AIA, LEED AP,

is a health care principal with HGA Architects and Engineers. He is co-author of Modern Clinic Design: Strategies for an Era of Change, with HGA colleagues Christine Guzzo Vickery and Gary Nyberg.

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 Hosea Ojwang, Human Resources Director at 612-626-1184, hojwang@bhs.umn.edu Apply online at http://www1.umn.edu/ohr/employment and search Keyword 306981. 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

MINNESOTA PHYSICIAN JUNE 2016

Physician Opportunities Essentia Health delivers on its promise to be “Here With You” and is guided by the values of quality, hospitality, respect, justice, stewardship and teamwork. OPEN POSITIONS INCLUDE:

Cardiology (EP & Noninvasive) Dermatology Endocrinology Emergency Medicine Family Medicine Geriatrics

Internal Medicine Neurology Ophthalmology Orthopedics Rheumatology Urgent Care

EOE/M/F/Vet/Disabled

PLEASE CONTACT

800-882-7310 | www.essentiahealth.org/careers

The perfect match of career and lifestyle. Affiliated Community Medical Centers is a physician owned multispecialty group with 11 affiliate sites located in western and southwestern Minnesota. ACMC 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 • General Surgery • Geriatrician • Outpatient Internal Medicine

• Hospitalist • Infectious Disease • Internal Medicine • OB/GYN • Oncology • Orthopedic Surgery • Pediatrics

• Psychiatry • Psychology • Pulmonary/ Critical Care • Rheumatology • Sleep Medicine • Urgent Care

F O R M O R E I N F O R M AT I O N :

Kari Lenz, Physician Recruitment | karib@acmc.com | (320) 231-6366 www.acmc.com |

Family Medicine Minnesota and Wisconsin We are actively recruiting exceptional board-certified family medicine physicians to join our primary care teams in the Twin Cities (Minneapolis-St Paul) and Central Minnesota/Sartell, as well as western Wisconsin: Amery, Osceola and New Richmond. All of these positions are full-time working a 4 or 4.5 day, Monday – Friday clinic schedule. Our Minnesota opportunities are family medicine, no OB, outpatient and based in a large metropolitan area and surrounding suburbs. Our Wisconsin opportunities offer with or without obstetrics options, and include hospital call and rounding responsibilities. These positions are based in beautiful growing rural communities offering you a more traditional practice, and all are within an hours’ drive of the Twin Cities and a major airport.

Family Medicine & Emergency Medicine Physicians

Great Opportunities

• Immediate Openings • Casual weekend or evening shift coverage • Set your own hours • Competitive rates • Paid Malpractice

HealthPartners continues to receive nationally recognized clinical performance and quality awards. We offer a competitive salary and benefits package, paid malpractice and a commitment to providing exceptional patient-centered care. Apply online at healthpartners.com/careers or contact diane.m.collins@healthpartners.com, 952-883-5453, toll-free: 800-472-4695. EOE

healthpartners.com

763-682-5906 | 763-684-0243 michelle@whitesellmedstaff.com www.whitesellmedstaff.com JUNE 2016 MINNESOTA PHYSICIAN

Targeted temperature management from page 11

10 in the normothermia cohort. The final analysis demonstrated favorable outcomes in only 27 percent of the TH cohort and 37 percent of the normothermia cohort, a result that was statistically significant. It is clear that although TH may control elevated ICP, its use does not improve survival or neurological outcome and should not at this time be used for patient management. Hypothermia after spinal cord injury There will be an estimated 12,500 new spinal cord injuries in the U.S. in 2016 with an estimated 240,000 to 340,000 patients living with the diagnosis (National Spinal Cord Injury Statistical Center). The estimated lifetime cost, which is dependent on age, is between $1.1 million and $4.7

million per patient. An investigational prospective study demonstrating the safety and feasibility of systemic hypothermia after spinal cord injury was published in 2013, prompting the American Association of Neurological Surgeons and the

10 years to recruit 20 subjects. The complexity of spinal cord injury (multiple types and extent of injury exist) and its decreasing incidence in the developed world mean that a well-designed, large multi-centered randomized clinical trial

injury most likely does not improve either patient mortality or neurological outcomes. A more realistic interpretation of the currently available clinical data may be that TTM in the acute setting (maintaining a physiologically normal body temperature using active cooling techniques) may be the more meaningful intervention.

â&#x20AC;&#x153;There is uncertainty about the optimal target temperature, how it is achieved, and for how long temperature should be controlled.â&#x20AC;? American Heart Association

Congress of Neurological Surgeons to strongly recommend that randomized controlled studies be performed. Unfortunately, the study currently being run by the University of Miami has struggled with patient enrollment and the only other published study required

MINNESOTA PHYSICIAN JUNE 2016

with a long period of patient follow up (perhaps greater than five years) will be difficult to coordinate and complete. Conclusions It has become increasing clear that TH after a neurological

Charles R. Watts, MD, PhD, is assistant

professor of neurosurgery at Mayo Clinic College of Medicine, Mayo Clinic, Rochester and is board-certified in neurosurgery, surgery critical care, and neurocritical care. He is also a practicing emergent hospital-based neurosurgeon at St. Maryâ&#x20AC;&#x2122;s Hospital and a member of the Department of Neurosurgery, Mayo Clinic Health System, La Crosse, WI where he treats emergent and elective patients.

rehabilitate a body, we start T owith the mind and soul. If you or someone you know needs rehabilitation after an accident, surgery, illness or stroke, we have a simple premise for you to consider: To recover physically, you need support mentally and emotionally. How positive and how determined someone is can make all the difference. We believe the most effective therapy treats your body, mind and soul. Thatâ&#x20AC;&#x2122;s our approach. Post-acute rehabilitation services from the Good Samaritan Society are offered at multiple inpatient and outpatient locations throughout Minnesota and the Minneapolis/St. Paul area.

To make a referral or for more information, call us at (888) GSS-CARE or visit www.good-sam.com/minnesota.

The Evangelical Lutheran Good Samaritan Society provides housing and services to qualified individuals without regard to race, color, religion, gender, disability, familial status, national origin or other protected statuses according to applicable federal, state or local laws. Some services may be provided by a third party. All faiths or beliefs are welcome. ÂŠ 2015 The Evangelical Lutheran Good Samaritan Society. All rights reserved. 15-G1553

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MINNESOTA PHYSICIAN