Volume XXV, No. 3
June 2011
The Independent Medical Business Newspaper
Informatics education Optimizing electronic documentation By Susan Thompson, MBA, RN; Teri Verner, BSN, RN; Laura Sandquist, RN-BC, BSN; Beverly Collins, RN, PhD-C; and Bonnie L. Westra, PhD, RN, FAAN
B
D E S I G N with dignity
A day in the life: experiencing long-term care
In order to better understand the challenges that residents face living in a skilled care center, I asked a client if I DESIGN to page 10
PAID
A
t a conference on aging, a presenter asked the audience, “If you could take only one item to a nursing home with you, what would it be?” As the room rang with stories of pocket watches, love letters, and photo albums, I realized that these items represented different symbols for the same possession: family. Since that conference, the focus of my design in senior care communities has been creating an environment that supports residents, their loved ones, and the providers who care for them. Every room in a care center offers an opportunity for residents to
PRSRT STD U.S. POSTAGE
By Alanna Carter, Assoc. AIA, LEED-AP
live with autonomy, dignity, and independence. As we age, even though our day-to-day tasks change and our lives stop revolving around careers, there remains the desire and need for family, a need to feel connected to others, and a need to feel valued. In order to create an environment that supports each senior’s whole self, I felt that as a designer, I must first walk in his or her shoes. And that’s exactly what I did.
Detriot Lakes, MN Permit No. 2655
User-friendly long-term care
y 2015, all health care providers will need to use interoperable electronic health records (EHRs) in meaningful ways or pay a penalty. The federal Office of the National Coordinator (ONC), which is part of the Department of Health and Human Services, has allocated billions of dollars to support providers in meeting these requirements. Starting this year, the Centers for Medicare & Medicaid Services (CMS) is providing incentive payments to physicians and other eligible providers as well as hospitals to meet stage 1 criteria for meaningful use. Stage 2 and stage 3 meaningful use criteria are still under development. The goals of using an EHR are to streamline the workflow, support INFORMATICS to page 12
IN THIS ISSUE:
Medical facility design Page 22
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CONTENTS
JUNE 2011 Volume XXV, No. 3
FEATURES Design with dignity User-friendly long-term care
1
MINNESOTA HEALTH CARE ROUNDTABLE
By Alanna Carter, Assoc. AIA, LEED-AP
Informatics education Optimizing electronic documentation
1 T H I R T Y- S I X T H
SESSION
By Susan Thompson, MBA, RN; Teri Verner, BSN, RN; Laura Sandquist, RN-BC, BSN; Beverly Collins, RN, PhD-C; and Bonnie L. Westra, PhD, RN, FAAN
Health Care Architecture Honor Roll
22
DEPARTMENTS CAPSULES
4
MEDICUS
7
INTERVIEW
8
CHRONIC DISEASE Visiting asthma at home
20
By Kathleen Norlien, MHA
Accountable to Whom? ORTHOPEDICS Ankle injuries
38
By Sumner McAllister, MD
Brock Nelson
SPECIAL FOCUS: MEDICAL FACILITY DESIGN 30
By Michael Hagen and Don Rolf
Rethinking mental health care facilities
Thursday, October 13, 2011 1:00 – 4:00 PM • Duluth Room Downtown Mpls. Hilton and Towers
Regions Hospital
Condensed schedule, expanded facilities
Accountable Care Organizations
32
By Brian R. Buchholz, AIA, CID; Rick Dahl, AIA; and Don Thomas, CID
The Independent Medical Business Newspaper
Background and focus: Created as part of national health care reform, accountable care organizations (ACOs) are now part of every health care policy discussion. As defined by the 111th Congress, ACOs are organizations that include physicians, hospitals, and other health care organizations with the legal structure to receive and distribute payments to participating physicians and hospitals to provide care coordination, invest in infrastructure and redesign care processes, and reward high-quality and efficient services.
Exactly what this means is unclear, and a confusing array of levels and qualifications for ACOs has been proposed. With 2012 as a start date for Medicare reimbursement through ACOs, Congress is developing firm definitions at this time. Some say ACOs turn physicians into insurance companies; others say they are a way for physicians to take a leadership role in fixing a broken system. As health care organizations race to join, create, or redefine themselves as ACOs, they all face more questions than answers. Objectives: We will review the history, goals, and rationale behind the ACO model. We will review the latest federal guidelines defining what an ACO can be. We will discuss how the ACO will affect health insurance companies, employers, and the pharmaceutical industry. We will illustrate what must not be allowed to happen if the model is expected to succeed. We will examine who decides if ACOs are successful and how those decisions will be made. We will explore why so many people, representing very different perspectives on health care, are opposed to the idea and what can be done for it to achieve its best potential.
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JUNE 2011 MINNESOTA PHYSICIAN
3
CAPSULES
Allina, North Memorial Reach Deal on Clinic North Memorial Health Care is selling its 50 percent share of an outpatient medical clinic in Plymouth to Allina Hospitals and Clinics. Officials with North Memorial and Allina Hospitals and Clinics—which already owns the other halfshare of the WestHealth clinic— announced the transaction recently. No other financial details were released. WestHealth was founded in 1992 as a partnership between Allina’s Abbott Northwestern Hospital and North Memorial. It has more than 50 primary care and specialty physician offices, and offers same-day surgery, urgent care, laboratory, and imaging services.
Heart Attack Victim Survives 96 Minutes With No Pulse A heart attack victim who was without a pulse for 96 minutes
survived to make a complete recovery due to CPR efforts and a piece of new technology, according to an article in Mayo Clinic Proceedings online. The victim was given continuous CPR and a series of defibrillator shocks, but still lacked a pulse, the report says. Responders kept their efforts up because a measurement of how blood is flowing through the lungs to organs, called capnography, showed good blood flow. Use of the technology, which is usually found in operating rooms, was unusual in this situation, but Roger White, MD, says the extra effort kept the patient alive. “A pulse gradually returned,” White says. “The effort was successful in large part because of capnography, which informed emergency workers that if they persisted, it was conceivable they’d have a survivor on their hands.” The patient was flown to St. Marys Hospital in Rochester after his pulse resumed, and was treated for a blocked artery. “To our knowledge,” White says,
“this episode is the longest duration of pulselessness in an out-of-hospital cardiac arrest that ended with a good outcome. The case suggests further study of advanced life support techniques is warranted, as well as the use of real-time technology like capnography that can validate the efficacy of resuscitation efforts.”
AHRQ Sees Essentia Program as Possible National Model A federal agency in charge of promoting quality innovations in health care is considering a Minnesota telehealth program as a possible nationwide model. Officials with Duluth-based Essentia Health say the Agency for Healthcare Research and Quality (AHRQ) recently discussed how a technology used in the Essentia Health Heart Failure Program might be adopted on a national scale. The program, formerly known as the St. Mary’s Duluth Clinic Heart Failure Program,
began more than a decade ago, but its use of a telemonitoring scale that records a patient’s weight at home and transmits data to the patient’s clinic has posted dramatic results in fighting congestive heart failure. The device also can ask patients questions about their health and send the results to a cardiac nurse, allowing monitoring of a patient’s progress and medications. Essentia officials say that while national hospital readmission rates for congestive heart failure at six months are 40 percent to 50 percent, the telescale program shows much better results. The program’s sickest patients have readmission rates at 2 percent and under, with readmission rates for all patients in the program ranging from 3 percent to 7 percent. Officials add that an Essentia study in collaboration with Blue Cross and Blue Shield of Minnesota found the program resulted in $1.25 million in savings for just 29 patients over a six-month period. The impressive results led
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AHRQ to showcase the program at a recent meeting of the Health Care Innovations Exchange. The meeting included a discussion on how the Essentia program’s success could be replicated at other health systems around the country. “The Innovations Exchange does a rigorous review of programs before deciding to share them nationwide,� says Linda Wick, NP, Heart Failure Program manager for Essentia. “Our Heart Failure Program is proven to improve patients’ care while decreasing costs.�
MDH Issues Warning About Tick Season As tick season arrives in Minnesota, officials with the Minnesota Department of Health (MDH) are reminding people that 2010 saw a record number of cases of tick-borne diseases. Minnesotans, they say, should increase their efforts this summer to protect themselves from ticks. The biggest increase in tick-borne disease cases in 2010 was the 720 cases of human anaplasmosis, more than double the 300-plus cases found in recent years. There were 56 cases of babesiosis, up from 31 in 2009, and 1,293 cases of Lyme disease, up 21 percent from 2009, officials say. “We’re seeing a continuing and troubling trend of marked increases in cases of tick-borne diseases in Minnesota,� says Dave Neitzel, MDH epidemiologist. “We are particularly concerned about anaplasmosis, with case numbers now rivaling Lyme disease in some areas of the state.� MDH officials say tickborne illnesses can range from mild to severe. Complications can include swelling of the brain, organ failure, and death. About 30 percent of the 2010 anaplasmosis patients were hospitalized, and one patient died. Nearly half of the babesiosis cases were hospitalized and one patient died. “With Minnesota’s more common tick-borne diseases reaching epidemic levels in some areas, it is crucial that
Minnesotans protect themselves from tick bites to prevent serious tick-borne illness,� says Ruth Lynfield, MD, Minnesota state epidemiologist.
Hospitals’ Profits Up, Report Finds Twin Cities hospitals bounced back from a rough 2008 to post relatively good margins in 2009, the latest report from Allan Baumgarten finds. The latest installment of Baumgarten’s twice-yearly report on Minnesota hospitals and health plans found that Twin Cities hospitals enjoyed their best profits in years, with a 6.5 percent overall margin. Outstate hospitals saw slightly lower income, but still posted a 6.2 percent margin in 2009. According to Baumgarten, Twin Cities hospitals have had steady profit margins since 2001, with the exception of 2008. That year, North Memorial Hospital in Robbinsdale and Methodist Hospital in St. Louis Park both sustained non-operating losses in areas such as investments. In 2009, the report finds, the two hospitals improved their finances and the result was a much better year overall for Twin Cities hospitals. The report says that inpatient hospital days actually declined in 2009, but patient revenues for hospitals increased by 5.8 percent. In 2009, metroarea hospitals posted a net income of $485.6 million, compared with a previous peak of $319 million in 2005. “One of the major findings of the report is the decline in inpatient days,� Baumgarten says. There could be several reasons for the decline, Baumgarten says, including things like the increased use of outpatient surgery and differences in year-to-year severity of flu season. “You’d be surprised in how much difference a heavy flu season can make compared to a light flu season,� he says. The report also finds an overall reduction in utilization, which Baumgarten says may be due to the fact that health plans
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CAPSULES to page 6 JUNE 2011
MINNESOTA PHYSICIAN
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CAPSULES
Capsules from page 5 are using higher deductibles and shifting costs to consumers. This affects consumer behavior, especially in tough economic times, Baumgarten notes. “They’re thinking twice and three times about whether or not they really need that knee procedure,” he says. Another notable development in the Minnesota hospital market is the consolidation of outstate health systems in recent years, Baumgarten says. With Sanford Health acquiring a number of hospitals and clinic systems in the western part of the state, Essentia Health dominating the northern part of Minnesota, and Mayo Health System owning many of the facilities in the southern part of the state, Baumgarten says he is planning to change the way he lists outstate hospitals in future reports. “You go down that list of outstate hospitals, and all but two or three are now connected to one of the systems,” he notes. The new report also looks at health plan enrollment in
Minnesota. For HMOs in the state, enrollment in employersponsored plans continued to decline in 2009, but overall health plan enrollment was up due to growth in Medicaid and Medicare plans. “Those increases in Medicaid, MinnesotaCare, and Medicare Advantage are actually offsetting the decline in enrollment on the employer side,” Baumgarten notes.
Walking Prescribed For Patients with Depression HealthPartners Medical Group will prescribe walking as an additional tool for treating depression, along with medication and/or therapy. HealthPartners officials note that an estimated 19 million Americans are living with depression and most of them first seek help in a primary care setting. With research showing that physical activity can improve mental health, HealthPartners providers will prescribe exercise as part of a
comprehensive approach to treating depression. The health system has created a program that gives pedometers to patients to encourage them to exercise by walking. HealthPartners officials note that a more extensive exercise program may seem overwhelming to patients with depression, so walking is a first step in helping patients begin to exercise. “The pedometer program is not meant to replace medication or therapy that may be beneficial to the patient,” says Art Wineman, MD, regional assistant medical director. “But it can be an effective tool in our toolkit for patients. Exercise works because it increases the feel-good chemicals in your brain. It also improves energy, relieves anxiety, and helps sleep.”
Mayo and Altru Announce Partnership
Come Listen!
new partnership that will allow the two health systems to work more closely together. Grand Forks, N.D.-based Altru has had a relationship with Rochesterbased Mayo Clinic for some time, but the new arrangement will extend Mayo Clinic’s resources to more of Altru’s patients, officials say. “This agreement is the natural next step in this relationship,” says Casey Ryan, MD, president of Altru Health System. “Altru and Mayo share the commitment that health care should be provided close to home whenever possible. This affiliation means that Altru’s patients will have access to the highest level of clinical expertise.” According to officials with the two groups, the development is not an acquisition of Altru— the organization will maintain its independence—but it will allow Altru physicians and facilities to have more access to Mayo Clinic resources.
Mayo Clinic and Altru Health System last week announced a
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MINNESOTA PHYSICIAN
JUNE 2011
MEDICUS
Nancy Hutchison, MD, a physical medicine and rehabilitation specialist, was elected chairwoman of the National Lymphedema Network Medical Advisory Committee at the group’s annual meeting in Chicago. Hutchison is medical director of the Sister Kenny Cancer Rehabilitation Program, a collaboration of Allina’s Sister Kenny Rehabilitation Institute and the Virginia Piper Cancer Institute–Abbott Northwestern Nancy Hutchison, MD Hospital. The National Lymphedema Network also presented Hutchison with a Lymphedema “D� Day Award in recognition of her “compassion and dedication to the treatment of lymphedema patients and the field of lymphology in the United States.� Kenneth Ripp, MD, is the new chairman of Integrity Health Network’s board of governors, succeeding outgoing chairman Daniel P. Kenneth Ripp, MD McKee, MD, of Northland Gastroenterology in Duluth. Ripp, of Raiter Clinic in Cloquet, previously served as the board’s vice chair. Integrity Health Network represents 46 care centers across northern and central Minnesota and northwestern Wisconsin, including more than 200 physicians from 20 fields of medicine, serving 20 communities. Heather E. Gantzer, MD, FACP, has begun her four-year term as governor of the Minneapolis chapter of the American College of Physicians (ACP), the nation’s largest medical specialty organization. Gantzer will work with the local council to supervise ACP chapter activities, appoint members to local committees, preside at regional meetings, and serve on the ACP Board of Governors. Board-certified in internal medicine, Gantzer earned her medical degree from Washington University School of Medicine in St. Louis. She completed a residency and chief residency at Hennepin County Medical Center. Gantzer is a full-time internal medicine primary care physician at the Park Nicollet Clinic in St. Louis Park, Minn. She is also part of the nocturnist hospital service at Methodist Hospital in St. Louis Park. James Vodvarka, DO, recently joined the St. Luke’s (Duluth) health care team as an internal medicine specialist at Hibbing Family Medical Clinic and Laurentian Medical Clinic. Vodvarka received his doctor of osteopathic medicine degree from the University of New England College of Osteopathic Medicine in Biddeford, Me. He completed his internship at Central Medical Center and Hospital in Pittsburgh, Pa., and his residency in internal medicine at West Penn Hospital in Pittsburgh. Dave Moen, MD, has been named president of Fairview Physician Associates (FPA). In addition to his role as FPA president, Moen will continue to serve as Fairview’s executive medical director of care model innovation and network Dave Moen, MD development. Moen, an emergency medicine physician, has held various leadership roles, including medical lead for Fairview in partnership with Target Corporation, medical director of emergency and urgent care at Fairview Lakes Medical Center, member of the executive committee of the Fairview Lakes Health Services board of directors, member of the board of directors for Lakes Region Services, and board member for the Minnesota Chapter of the American College of Emergency Physicians. Daniel Hanson, MD, FAAOS, a spine surgeon with Midwest Spine Institute, has begun seeing patients at Northwest Family Physicians’ location in Rogers, Minn. Hanson completed his medical degree at the University of Minnesota and his residency in orthopedic surgery at Indiana University in Indianapolis. He completed a fellowship in spine surgery at Spine Surgery PSC, in Louisville, Ky., and with the Indiana Spine Group in Indianapolis. Hanson is boardcertified and is a member of the American Academy of Orthopedic Surgeons and the Norwegian-American Orthopedic Society.
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MINNESOTA PHYSICIAN
7
INTERVIEW
Regions strives to lead market in quality of care ■ Please discuss the evolution of Regions Hospital.
Brock Nelson Regions Hospital Brock Nelson is president and chief executive officer of Regions Hospital. He has led Regions since 2003, and previously was chief executive officer at Children’s Hospitals and Clinics of Minnesota. Nelson has a degree in economics from St. Olaf College in Northfield, and a master’s degree in health care administration from the University of Minnesota. He serves on the board of directors for the Greater St. Paul YMCA, the Minnesota Hospital Association, and Capital City Partnership.
been the biggest changes in how doctors What became Regions was started originally by work with hospitals? Ramsey County in support of the safety net, and has quite a history and legacy around teaching. It In the last decade the biggest change has been became St. Paul Ramsey in 1965. In 1987, it sepaaround physicians and how they work with the sysrated from the county, although it continued to tems. Primary care has almost all moved to larger hold all the same responsibilities and duties. That organizations. There are a number of reasons for was important because it separated the nonprofit it. There are electronic medical record costs, there world from the government world in health care. is the sustainability of the primary care model, In 1993, one of the most significant moves in which suffers from insufficient cash to grow and this market occurred when Ramsey joined expand. So the primary care in this market is all HealthPartners. It happened on the day I went getting aligned. That’s been a major change. to hear Hillary Clinton speak at Northrop AudiThe specialists have generally been trying torium. Bob Garland, the CEO of Ramsey, was to remain independent, but you see increasingly sitting in front of me. He leaned back and said, systems will have specialists within them. “We’re joining HealthPartners.” It changed the HealthPartners does it, Park Nicollet does it. landscape in the East Metro market. Mayo historically is an example of that. For us what has evolved is our ability on the If you try to manage what’s optimal patient care delivery side to pursue a Triple Aim—having care, from primary care to specialists, and you high-quality care, providing a great experience, tie that to total cost, it goes back to an integrated and addressing the total cost of care. system. That’s what we’re trying to do. Mayo, the We’re able to do that Cleveland Clinic, Johns because of the HealthHopkins all have a system We’ve made a major effort where it’s all linked together. Partners medical group. HealthPartners has a large And the patients benefit to change the reality primary care organization. because you have easier of this organization, Since I’ve arrived, we’ve access. made an attempt to recruit Medical records aspects but also the perception. more specialists and really are shared, payment is simfocus on best care, best plified, there are a lot of very experience, along with the third leg of the Triple good reasons why it’s been effective and successful. Aim, which is being affordable If you can manage a population, you can deal with So we’ve made a major effort to change the patient-specific needs, you can link primary care to reality of this organization, but also the perception. specialty and ancillary services, and you can deal We’re not a second-tier hospital. We’re going to be with the total package. You are in a better position. a market leader around quality of care, and we’re ■ Do you see the specialist practice following the going to have the best doctors in this market worktrend that primary care has? ing for us. We’re unabashed about that. We’re bullish on it, because that’s just what it takes. It will. People might have thought that surprising; it’s not surprising. You’ll see other specialties go ■ In general, how has the role of large metropolithe same way. There will be some that are more tan hospitals changed in the past decade? resistant, because they have stronger footholds or Over the last decade it hasn’t changed much, and they have a level of specialization that competing I think that’s because of where the market had organizations can’t duplicate. come to. This market is consolidated to a handful We have a really good relationship with St. of systems—Allina, Fairview, HealthEast. The flagPaul Radiology. They have expertise we can’t bring ship hospitals of those entities have continued to in-house. Orthopedics is independent; I think evolve, but they’re still going; there haven’t been they’ll be able to hold out. But if you look at things closures. There were closures earlier with consolilike urology, ENT, gastroenterology, we’ve brought dation. You saw that here in St. Paul with some them all inside. We’ve brought cardiovascular surof the HealthEast facilities, you saw it with gery inside. We’ve brought neurosurgery inside. HealthOne and Metropolitan Medical Center, but The specialists over time will align with systems, not recently. And it’s the result of an oligopoly provided that they can have an adequate range of theory in economics that you see play out in health specialization and an adequate patient base to supcare. port their needs. It’ll just be a matter of time. Lakeview Health System in Stillwater has been ■ With reimbursement for government programs the most recent acquisition by HealthPartners, but continuing to decline, what strategies are being apart from that there hasn’t been a great deal of considered by Regions to stay financially viable? consolidation in the metro area. You see it outstate with Mayo, Sanford Health, and Essentia Health.
8
■ From the Regions’ perspective, what have
MINNESOTA PHYSICIAN JUNE 2011
Let me talk first about the issues at the Legislature. They’re trying to solve the state budget by further
reductions in public programs. It clearly impacts us, Hennepin County Medical Center, North Memorial, and the University of Minnesota Medical Center–Fairview the most. Which is unfortunate, because it’s not equitable. The irony is that the people who make up for the deficit from public programs are all the commercial patients. The businesses are paying for what the government’s not paying for. What we’re doing is, first, working very strongly legislatively at a policy level. We’re working very closely with HealthPartners for growth, and whether it’s in the local markets, additional primary care, or western Wisconsin, there are opportunities for growth that we’re working on. Here at Regions we’re also developing a level of services that will outperform others. This is a very high-performing market but if you need heart care, we want to be better than others. If you need hip or knee replacement, it’s better here. Cancer care is better here. We’ll put our heart surgery and our neurosurgery against anybody in this town; they’re that good. ■Talk a little about Regions’ relationship
with HealthPartners. I’ll start with how you get to Regions. We have a strong emergency department program. We follow up our ED patients with
visits scheduled to the patients’ clinics. We’re able to do that because many of our ER patients are HealthPartners’ medical group patients, and we have electronic medical records. If I had come to the hospital last night, my primary care doctor would’ve known about it this morning, because he has access to my medical record. On the primary care side, if I go to my primary care doctor and I have a need to use the hospital, they schedule it, they handle it, everything is on the electronic medical record. That’s a huge advantage. The third part is that we’re working with hospitals in western Wisconsin. We believe that care is best provided locally, to the extent that technology and services are available. So when we work with New Richmond, Hudson, or Amery, we want those patients to be cared for in those communities. But if they need services like specialized surgery that they can’t have done there, we’re connected to them. The last area around our plan for growth as well as our connection to HealthPartners is some of our specialized programs. Mental health is a good example. HealthPartners has been involved in several community-based meetings around that. We are there with them as the acute-care piece of that puzzle. ■How will Regions and HealthPartners
Organization (ACO) model envisioned by the federal health care reform law? We’re addressing it with HealthPartners at a foundational level. Around how we serve our population, how we improve their care, and then how to have an affordable rate. We are relying on HealthPartners for the policy discussions and how practically it plays out. [The ACOs are] very complex; there are all these moving parts. Physicians are welltrained, they’re very bright, and yet to explain it to a group of professionals, it’s confusing. You talk about inside baseball— it’s hard to know what park we’re in. It’s challenging. ■What are your goals for Regions over the
next five to 10 years? It’s continuing execution on the path we’re on regarding Triple Aim. It’s continuing to differentiate ourselves at a higher level than others in our market. In many respects that sounds like what we’ve been doing over the past several years, but we’re going to keep playing it out. The failure of most organizations is not around strategy, it’s around execution. If you can’t execute, it’s all words. On the organizational side, we need to have every one of us inside this organization believing and behaving and performing in a way that provides that very best care and experience to the patient—every time.
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Design from cover could spend 24 hours as a resident in her care center, a building developed in the 1960s as a model medical institution. I was admitted in the morning and given a stroke diagnosis and associated care plan. The right side of my body was immobilized, and I was in a wheelchair. Being in a wheelchair inhe-
design, I quickly found myself more preoccupied with an emotional struggle. As I made my way to the dining room, lifts and medical carts cluttered the hallways due to a lack of storage, making it very difficult for me to make my way down the narrow corridors. Another challenge was presented by the transition strips located between the carpet and hard surfaces. The
clutter in the corridors, I was not able to access the handrails along the wall. Handrails would have allowed me to pull myself down the corridor, enabling me to maintain some independence and not feel so defeated. When I finally made it to the central dining room, I wanted to get to know my tablemates. Unfortunately, the capacity of this dining room was 70
We design with the focus on supporting the individual. This is culture change.
rently takes away some of the independence a person could be used to, but this helped me to see firsthand other obstacles associated with the inability to move on my own. Even though my main focus was identifying physical challenges posed by the buildingâ&#x20AC;&#x2122;s
height differential made it very difficult for me to get my wheelchair through the doorway and into the dining room. After a couple of failed attempts, my 32-year-old independent spirit was broken and I found it easier to depend on the staff to transport me. Because of the
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people. Since there was a fixed food schedule, all 70 residents were eating while the staff pushed squeaky metal carts and tried to coax residents to finish their meals. I could not even hear myself think, let alone the question a woman sitting beside me asked. Given that mealtimes are traditionally a time of socializing and connecting, this was a lost opportunity to bond with my fellow residents. The physical design challenges were considerable, but the biggest lesson I learned from this experience was that though the built environment is important, the greatest opportunity to positively affect a residentâ&#x20AC;&#x2122;s life lies with the caregivers. Not long after arriving, my morning cup of coffee kicked in, and I needed assistance going to the bathroom. I pulled the cord and the assistant came, then helped get me onto the lift and began unbuttoning my pants. Iâ&#x20AC;&#x2122;m sure that this was a completely insignificant task for the assistant, but for me it was an awakening to the awareness of how little dignity is left for residents of a care center, and how little self-care they are able, or allowed, to do themselves. When stripped of dignity and the ability to care for oneâ&#x20AC;&#x2122;s self, or contribute meaningfully to life, it is understandable how a reason for living, and the will to live, can fade.
After my experience in a care center designed under the medical model, I made a promise to myself not to design nursing homes this way any longer. We design with the focus on supporting the individual. This is culture change. It is a way of approaching design to support a personâ&#x20AC;&#x2122;s needs, wants, and desires at the center of the design. It is not only the design of the physical building that provides this support, but also the way in which care is delivered. The goal of the culture change model is to transform nursing homes into comfortable environments that support dignity and self-determination, and foster a sense of home. The model develops places where residents are supported in being as independent as possible, and where visitors are comfortable spending the day with loved ones. â&#x20AC;&#x153;Back to basicsâ&#x20AC;? design
So how do you design for this environment? Itâ&#x20AC;&#x2122;s simple: Go back to the basics. At the core of culture change is home. Homes are associated with independence. Care centers operating under the culture change model strive to be as close to home as possible while still providing state-of-the-art care. Here are some strategies used to achieve this. Flexible wake-up schedules. No longer is there a fixed, one-schedule-fits-all mindset. Residents wake up on their own instead of having the staff wake everyone up on a predetermined schedule. Not only does this give residents more selfdetermination and independence, but residents are also more rested throughout the day. Thus, they tend to participate in more activities, interact socially with peers and staff, and have a better appetite. Open dining plan. Another change is to have household serving kitchens with attached dining rooms that serve the 10 to 20 residents of that household instead of a central dining area. Similar to the flexible
wake-up time, open dining permits residents to eat on their own schedule. Serving kitchens in each household allow staff members to double as short-order breakfast cooks, so residents can have a warm breakfast of their choosing, whenever they get up. This supports greater connection between residents and staff, as residents can sit at the counter and talk with providers while watching breakfast being made, smelling familiar smells, and hearing the familiar sound of dishes being washed. Improved resident/staff interaction. The idea of better staff/resident interaction is an important aspect of the culture change model. In the past, the nurses’ station was at one central desk. Staff spent most of their time in this fixed location and only navigated away to check on the residents when a problem arose. Centralized nursing keeps providers and residents separate; thus, culture change stresses decentralized nursing. In the new model, staff and residents work, live, and socialize together. Charting and other tasks take place on a comfortable couch in a resident “household” living room instead of at a desk chair behind a behemoth nurse station, again enhancing and extending staff interaction with residents. Technology also furthers decentralization efforts. Staff are available to one another at all times via text messaging and phone calls, making institutional overhead paging obsolete. Accommodation of visitors. Another important element in design is catering to visiting family and friends. The culture change model takes steps to ensure that visitors are comfortable spending time in the facility. For example, the smells of ammonia and images of stained carpets have cast a dark shadow in the minds of many individuals. Fortunately, new technological advances can help erase these negative connotations. Now, there are carpet tiles that can be quickly and easily replaced when soiled, and prod-
My research as a resident within a nursing home was invaluable, resulting in a whole new perspective on designing senior communities. ucts that eliminate ammonia from fibers to reduce the acrid smell. In addition, many facilities now offer wireless Internet connection and have coffee shops and gift shops that residents and their guests will appreciate. Creating a home-like atmosphere
Designing for a home-like environment is a key concept in a senior living center layout. Traditional models have included a large central communal kitchen and dining area. As my experience in a nursing home confirmed, central dining rooms are loud, crowded, and public, and make conversation and connections difficult. Furthermore, in older facilities everything is shared—even the bedrooms, which commonly hold two to four residents. In contrast, the culture change model includes public, semi-private, and private places. Mirroring the familiar idea of living in a house, a facility is separated into smaller cottages, each housing 12 to 20 residents. This arrangement supports improved care for residents in many ways: • There is a better staff-to-resident ratio, allowing for better, more personalized care. • The family-oriented environment encourages stronger social bonds among the residents. • Residents have more privacy because they are sharing their immediate living space with only a handful of others, rather than with 40 to 80 people on a large, impersonal ward. The culture change model notes the importance of normal social patterning, and designs in a hierarchical household system are based on this principle. For example, when residents
walk into their cottage, they enter a lobby area that brings to mind a household porch or foyer. This is a common area where residents can meet and greet visitors, staff, and other residents, but need not feel obligated to allow them passage further into their home. Next in the layout is the kitchen. This serves as a semiprivate space where residents in the household can come and go as they please and visit with friends and family. In the back of the cottage are the bedrooms. Each resident has his or her own room, offering complete privacy. Residents can decorate their rooms as they wish, to create a comfortable space that compli-
ments their personality and reinforces continuation of self. This is an area where residents can spend uninterrupted quality time with their family and friends. My research as a resident within a nursing home was invaluable, resulting in a whole new perspective on designing senior communities. Adopting the culture change model is a positive step toward offering seniors the dignity, independence, and overall environment that they deserve. For people who cannot safely stay in their own homes, designers can best support them emotionally and physically by creating a positive, homelike environment. After all, home is where the heart is. Alanna Carter, Assoc. AIA, LEEDAP, formerly was an associate principal at Horty Elving and now is director of senior environments at Mohagen Hansen Architectural Group. She is the founder and current president of Sage Minnesota (Society for the Advancement of Gerontological Environments).
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Informatics in the Doctor of Nursing Practice program The recent Institute of Medicine Report on the Future of Nursing emphasizes the importance of doctoral education for nurses to prepare them as leaders, particularly in a time of rapid health care change. The doctor of nursing practice (DNP) is a practice doctorate with specialties in areas such as nurse practitioners, nurse midwives, public health nursing, leadership, and informatics. Regardless of their specialty, all DNP students are required to take a graduate-level course in informatics; it is one of eight essential areas in the doctoral program. The course educates them about informaticsrelated health policies such as meaningful use of EHRs, certification standards for EHRs, and the application of informatics to continuity of care in the evolving accountable care organizations. Informatics education also emphasizes knowledge and resources for analyzing and workflow processes, terminology standards, integration of evidence-based practice into the EHR, and the value of reusing health care data for quality improvement and research. More information about the University of Minnesota’s DNP program is available at www.nursing.umn.edu/DNP/home.html. The University of Minnesota additionally offers an informatics certificate program applicable to any clinical or public health discipline. This is an online program that currently makes available up to $10,000 for eligible students to cover tuition through a grant from the Office of the National Coordinator. More information about the informatics certificate program can be found at www.nursing.umn.edu/cphli/home.html.
Informatics from cover clinical decision-making, and reuse the data to meet multiple requirements such as accreditation, quality improvement, or research. Accomplishing these goals requires that clinicians get involved in design or redesign of information systems. In the future, all clinicians will need at least some minimal competencies in informatics. Nursing programs are now required to address informatics competencies and it is anticipated that medical education will add a similar requirement. Additionally, medicine is now establishing a subspecialty in informatics. A grant from the Robert Wood Johnson Foundation funded the AMIA (formerly known as the American Medical Informatics Association) to develop informatics competencies for the medical informatics subspecialty, and the American Board of Primary Medicine is sponsoring a proposal for subspecialty certification through the American Board of Medical
Subspecialties. Most physicians will not be informatics specialists, but minimal informatics competencies can be valuable to engage physicians in optimizing EHRs to support their work. One example
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of an educational opportunity in informatics was provided by Allina Hospitals & Clinics for the University of Minnesota’s School of Nursing Doctor of Nursing Practice (DNP). Similar educational experiences can enable physicians to be active partners in shaping their EHR systems. A service-learning project
Allina implemented their EHR, Excellian (their branding of Epicare by Epic Systems), in 2004. It is a single integrated EHR. When Allina began implementation of their EHR, they had two major goals. The first was “One Patient, One Record.” This meant that the record would be at the fingertips of all care providers across care settings. The second goal was to implement the EHR quickly so its benefits could be realized. After the initial implementation, the focus shifted toward optimizing the EHR to further match the workflow of clinicians as well as enhance clinical decision support. Allina has collaborated with nursing students from the University of Minnesota’s School of Nursing DNP program to provide real-world experiences for learning about optimizing EHRs. In place of written assignments, students have the option to engage in service
learning, working with a health care system on projects such as optimizing EHRs. The example described below involved optimizing the documentation for care of patients with a total hip replacement. Prior to student involvement, Allina had developed a standardized pathway that is an evidence-based plan of care for total hip replacement patients while hospitalized. The goal for students was to evaluate how to best integrate the pathway into the workflow of the clinicians. Students first observed current documentation and workflow. They created activity and flow diagrams to identify gaps in the current processes and opportunities for improvement. The students then created a redesign for an ideal system that would connect planned care on the pathway to care documentation that would match how clinicians work and process information. The students also identified what and where “just in time” referential information might be embedded in the documentation process. Pathway to documentation of care. The plan of care for the total hip pathway and the documentation of care related to the pathway existed in separate parts of the chart. There was no intuitive way to ensure that all necessary information needed to document adherence or compliance with the plan existed. The students noted that nurses would go into numerous EHR screens to document care related to the total hip pathway. One observation noted that nurses were creating paper “cheat sheets” or lists to keep track of what they needed to do and whether the documentation was complete. Embedded referential information. Referential information was available but was not directly linked to the chart, resulting in wasted time finding the information such as patient teaching material or details of a procedure for nurses unfamiliar with some cares. As a result, nurses found it easier to simply ask a colleague for the informaINFORMATICS to page 19
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Informatics from page 12 tion when they couldn’t easily find it in the system. This process interrupted the their colleague’s workflow in addition to wasting the nurse’s own time. It’s important to note that the students were asked to design the ideal system without having any knowledge of the capabilities of Excellian. The advantage of involving students, rather than the IT agency staff, in the design is that the students did not feel constrained by knowing limitations that might exist in the system. The students’ design was taken to a team of clinical decision support and Excellian support staff for consideration of how or what parts might be integrated into Excellian. Their work is currently being piloted on units at Abbott Northwestern and Mercy Hospitals. If proven to be useful and approved by the clinicians who are trying it, the redesign recommendations will first be rolled out for the care of total hip replacement patients at all of Allina’s hospitals, and sub-
A major lesson learned is the crucial importance of analyzing the workflow from the perspective of multiple users. sequently the same methods will be adapted for documentation of other clinical conditions. Informatics partnership
The drive to implement EHRs emanates from the desire to ensure safe, effective, cost-efficient care for all of our patients. However, an EHR is not a magic bullet. There is still a lot to learn about how clinicians work and make decisions and, thus, how best to build, implement, and use these systems in a meaningful way. Physicians must be educated about informatics and involved in sharing their ideal vision of how a system can better support their work. The students involved with this project learned critical lessons about optimizing an EHR that complements their clinical
knowledge. The first lesson is that moving from paper-based documentation to an EHR needs to occur even if everything isn’t perfect. If we waited for everything to be perfect and stable, EHRs would never be implemented. Incremental change allows forward progress in use of EHRs, with successive learning about how to optimize systems. This is particularly the case with the staged approach for incentive dollars for meaningful use of EHRs. Over the next four years, change will continue to occur with significant dollars at stake for demonstrating measures for meaningfully using an EHR. In the future, additional saving will be achieved as health care staff learn how to chart consistently so quality measure reports can
be abstracted from EHRs rather than the duplicate work of manual chart reviews. Finally, a major lesson learned is the crucial importance of analyzing the workflow from the perspective of multiple users. When EHRs are designed to match the workflow of clinicians, significant time can be saved, errors reduced, and outcomes improved for patients. Susan Thompson, MBA, RN, Teri Verner, BSN, RN, and Laura Sandquist, RN-BC, BSN, are students in the Doctor of Nursing Practice program at the University of Minnesota School of Nursing. Beverly Collins, RN, PhD-C, is senior clinical informaticist for Allina Hospitals & Clinics. Bonnie L. Westra, PhD, RN, FAAN, is an associate professor at the University of Minnesota School of Nursing and is co-director of the International Classification of Nursing Practice Research Center for Nursing Minimum Data Sets & Knowledge Discovery.
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CHRONIC
Visiting asthma at home
A
sthma is one of the most common chronic diseases in the United States, disproportionately affecting women, children, and the poor. An estimated currently 24.6 million Americans have asthma, including 7.1 million children under the age of 18. It is the third leading cause of hospitalizations in children under 15. In 2009, asthma accounted for 444,000 hospitalizations and 1.7 million emergency department visits across the country. In 2007 alone, 3,447 people died of asthma. Asthma is greatly affected by exposures to allergens and irritants in the environment. Therefore, controlling these exposures can be an important component in asthma management. Both indoor and outdoor contaminants can trigger asthma attacks. Indoor biological-based factors include pets (animal dander), pests such as cockroaches and mice, and excess moisture, which can provide the environmental conditions where mold and dust mites thrive.
Helping children through control of asthma triggers By Kathleen Norlien, MS, CPH Chemical factors include tobacco smoke and chemicals released during the use of home cleaning and personal care products. Chemicals and particulates are also released as byproducts of combustion during home heating and cooking activities. Outdoor air pollutants that can enter homes through cracks and crevices include allergens from biological sources such as pollen and chemicals from industry and transportation. Many of the chemicals that can trigger asthma attacks—including ozone, particulate matter, sulfur dioxide, and nitrogen dioxide— are byproducts or formed by byproducts of combustion.
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Comprehensive care
In 2007, the National Institutes of Health published “Guidelines for the Diagnosis and Management of Asthma, Expert Panel Report-3.” The guidelines emphasize the importance of a multifaceted approach to asthma management and acknowledge that asthma is most effectively controlled with comprehensive care that includes both medical and environmental management techniques. Through two projects, the Minnesota Department of Health (MDH) has developed a program for combining low-cost environmental home interventions with in-home asthma education. The first project, Reducing Environmental Triggers of Asthma (RETA), focused on 64 children living in the Minneapolis–St. Paul area. Following the success of RETA, a new project, called Communities Reducing Environmental Triggers of Asthma (CRETA), was developed to replicate the interventions in three other venues: an urban city, a rural county, and an American Indian reservation. The RETA and CRETA projects demonstrated that homebased, multi-trigger, multi-component environmental interventions coupled with in-home medical management are effective in reducing symptoms days, school days missed, and the number of hospital visits and unscheduled (urgent care) office visits. The projects’ interventions improved daytime and nighttime symptoms and reduced functional limitations such as shortness of breath and nighttime awakenings. Equally important, these programs have been very effective in reducing costs. RETA project
Home visits provide an ideal setting to educate clients about
asthma, review medication plans, teach self-management skills, and help families identify environmental factors in their homes that may contribute to exacerbation of asthma symptoms. Sixty-four families participated in the RETA project and three-fourths of the children referred to this project were children with moderate or severe, persistent asthma. Participants received in-home asthma education from a certified asthma educator or public health nurse and appropriate materials or products to minimize or eliminate exposures to allergens and irritant triggers of asthma in the home. The most common products provided were HEPA (highefficiency particulate air) air cleaners, pillow and mattress dust encasements, and HEPA vacuum cleaners. Components of the home visits are summarized in the sidebar. A cost analysis revealed that under the first home-intervention project, RETA, the costs saved by reducing unscheduled office visits (urgent care) and hospital visits were greater than the costs of providing home visits and inexpensive products (such as pillow and mattress encasements) as part of the home interventions. The average cost of the initial visit and product interventions was $468 per child. For each child, the average number of reported office visits declined by two visits per year and the average number of reported hospital visits declined by one visit per child per year. The estimated cost of one hospital visit and two office visits is $2,428 (based on 2004 hospital discharge data and 2006 urgent care claims). Therefore, the estimated cost savings of the RETA project was $1,960 per child in this study. In addition to the cost savings, the number of school days missed declined from seven days to less than one day on average 12 months later. The need to use oral prednisone decreased by an average of one therapy regimen in 12 months. Participants also reported improvements in daytime symptoms and functional limitation scores. The post-intervention scores were dramatically closer to values generally viewed
Asthma information/resources • Asthma Program, Minnesota Department of Health: www.health.state.mn.us/asthma/ • Interactive Asthma Action Plan, Minnesota Department of Health: www.health.state.mn.us/divs/hpcd/cdee/asthma/ActionPlan.html • ”Guidelines for the Diagnosis and Management of Asthma (EPR-3),” National Institutes of Health: www.nhlbi.nih.gov/guidelines/asthma/ Components of a home assessment 1. Assess the status of the child’s asthma. • Is it under control? • Do they know where the medications are? • Do they know how to use their medications? • Do they have an Asthma Action Plan (AAP)? • Do they know how to follow their AAP? 2. Assess their home environment. • Does the client understand what triggers his or her asthma? • Identify potential asthma triggers. • Assess whether the home is dry, clean, safe, pest-free, controlling pollutants, has adequate ventilation, and is properly maintained. • Help facilitate behavioral change to reduce asthma triggers in the home such as proper cleaning, smoking cessation, and keeping the child’s bedroom trigger-free. 3. Educate the child with asthma and his or her family. 4. Provide durable medical supplies as needed. These supplies could include a plastic storage container for medications, an AAP, and products that can help the family to reduce potential asthma triggers such as a HEPA vacuum cleaner, a HEPA portable air cleaner, pillow and mattress covers. 5. Coordinate care. Low-income families may need additional resources and referrals, such as to social services. Minnesota asthma statistics
as moderate to no symptom impact on quality of life. Success stories
A public health nurse who was part of the CRETA project shared a success story about the home visiting program. “One of my clients is a 29year-old mother with five children, ages 11 months to 11 years. The four oldest children have asthma. When I first met her, none of the children had their asthma under control. My client was noncompliant with medication management because she thought Pulmicort was the rescue medication. She was unable to locate the asthma medications during my home visit and none of the children had an Asthma Action Plan (AAP). “Due to family circumstances, the client was not available for a 3-month follow-up visit. However, at the 6-month follow-up home visit, the client indicated how pleased she was with the program. She had received medical consults for each of the children to clarify their medication needs and had obtained an AAP for each child.
• 8.7 percent of children (age 0–17) have been diagnosed with asthma at some point in their lives. • 1 in 16 Minnesota children (approx. 76,000) currently have asthma. • The percentage of children in Minnesota with asthma (6 percent) is lower than the national average (9 percent). • 15.1 percent of Minnesota students in grade 6, 17.7 percent in grade 9, and 18.4 percent in grade 12 report that they have a history of asthma. • 9.6 percent of adults have been diagnosed with asthma at some point in their lives. • 1 in 15 Minnesota adults (approx. 260,000) report that they currently have asthma. • The percentage of adults in Minnesota with asthma (6.6 percent) is lower than the national average (8.8 percent). • Adults living in the Minneapolis–St. Paul metro area are more likely to have asthma than residents of Greater Minnesota (7.7 percent vs. 5.5 percent). • Women are more likely than men to report that they have asthma (7.7 percent vs. 5.5 percent). • Adults with asthma are more likely than those without asthma to report that their health is fair or poor, experience activity limitations, and be obese. • Rates of hospitalizations and emergency department visits for asthma are highest for: — Children less than 5 years old. — Residents of the Minneapolis–St. Paul metropolitan area. • In 2009, 60 residents died of asthma; 58 percent were 65 or older and 55 percent were women. Source: Minnesota Department of Health Asthma Program
The children have not missed school due to their asthma and, consequently, my client has not had to take time off from work for illnesses. “She stated that the air purifiers and bedding encasements in the bedrooms seem to have reduced the children’s nighttime symptoms dramatically and liked the HEPA Hoover vacuum very much. The client proudly demonstrated that she now stores the children’s medication in the plastic storage box provided through the grant.” Online training for providers
The MDH Asthma Program has produced an online training module to help health care providers learn about asthma triggers found in the home and provide simple interventions to limit exposure to those triggers. The training takes about 45 minutes, and a certificate of completion can be printed out at the end of the session. The training is at www.retahome.org. Kathleen Norlien, MS, CPH, is an environmental research scientist in the asthma program at the Minnesota Department of Health.
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health care architecture honor roll
Minnesota Physicianâ&#x20AC;&#x2122;s 2011 Health Care Architecture Honor Roll recognizes nine outstanding projects completed in the past year. This yearâ&#x20AC;&#x2122;s Honor Roll includes a variety of types of construction, services offered, and locations. The projects include clinic and hospital construction, remodeled spaces, and facility expansions in urban, suburban, and rural Minnesota. Their medical services range from routine clinic visits to long-term care, behavioral health care, and emergency care, for patients spanning the age spectrum from newborn to elderly. Though the facilities differ in intended uses and populations served, they share a focus on efficiency, safety, and patient-centered care, often through the use of advanced technology. This yearâ&#x20AC;&#x2122;s nominations also demonstrate a trend toward facilities that allow tenants to hire their own interior designers (see p. 28). Minnesota Physician Publishing thanks all those who participated in the 2011 honor roll.
University of Minnesota Amplatz Children’s Hospital Type of facility: Children’s hospital Location: Minneapolis Client: University of Minnesota Amplatz Children’s Hospital
Architect/Interior design: Tsoi/Kobus & Associates Contractor: Kraus-Anderson Construction Company Completion date: March 2011 Total cost: $119 million Square feet: 231,500 (pediatric bed tower); 95,000 (parking garage) The University of Minnesota Amplatz Children’s Hospital is designed to create the ideal environment in which to provide and receive children’s health care, emphasizing safety, comfort, and efficiency. It consolidates existing pediatric and inpatient units and includes a pediatric intensive-care unit. All 96 patient rooms are private and same-handed; at 390 square feet, they are approximately twice the industry average for size, allowing ample space for distinct provider, patient, and family zones.All rooms include sleeping accommodations for two adults, a microwave and refrigerator, a work area with an Internet connection, and an all-purpose “kitchen table.” Each of the facility’s four 24-bed units is designed as a modified racetrack broken into neighborhoods of six beds each.A decentralized floor plan locates diagnostic and testing services near their corresponding clinics and bed floors, cutting down on staff travel time. A corridor on each patient floor separates support services from patient and family spaces, contributing to quieter patient rooms. With its anodized stainless-steel exterior that changes color depending on the light, the building creates a distinctive identity for the hospital.Wall-to-wall expanses of glass provide daylight and views for patients, staff, and family.An interior theme,“Passport to Discovery,” features imagery from various ecosystems and recalls the hospital’s research mission.The theme, expressed on each floor, aids in wayfinding and offers opportunities for diversion. Left: The anodized stainless-steel exterior changes color depending on the light. Inset: The colorful lobby carries out the facility’s cheerful, energizing color scheme.
Edina Crosstown Medical Office Building Type of facility: Medical office building/ orthopedic specialty center Location: Edina, Minn. Client: Edina Crosstown Medical, LLC Architect: Mohagen Hansen Architectural Group Engineer: Dunham Associates, Inc. Contractor: RJM Construction Completion date: June 2010 Total cost: $17.25 million (building shell); $5.2 million (interior build-out); $12.25 million (parking garage) Square feet: 75,000 (building); 145,000 (371-stall parking garage) The demolition of an existing office building on the site made way for this dynamic new building and parking garage.The challenge was to develop a solution that met tenant Twin Cities Orthopedic’s needs for space on a site that inherently had many challenges, including an odd shape that limited building and parking setbacks, groundwater issues, a cell tower, numerous critical utilities crossing the site, and a zoning classification that would not allow for effective redevelopment of the property.The project demanded creative solutions to numerous challenges,
requiring input, compromise, and flexibility on the part of all involved. The design of the exterior curved canopy and landscaping features offers a pleasing street presence and softens the scale of the building.The interior space feels innovative while remaining comfortable and inviting. The contemporary design incorporates gentle curves that guide visitors through, along with creative materials used consistently throughout the entire space. Distinctly different yet complementary color schemes differentiate each clinic.The building shell and core received LEED gold certification from the U.S. Green Building Council. The final product is a functional, aesthetically pleasing health care environment that meets the needs of both the client and the community it serves. Top: The interior design concept carries through the curve of the facility’s exterior canopy. Below: The rooftop gardens contribute to sustainability and helped the facility earn LEED gold certification status.
HONOR ROLL
2 011 ship, will provide additional mixeduse development. The design team worked with the community and representatives of HCMC’s patient base to develop the exterior and interior character. Nearly half of the facility’s parking is located below grade, freeing surface space for community park and rain gardens.The primary entry features a public plaza and overhead trellis to welcome patients and community members. A playful mix of brick and metal panels minimizes the building’s scale along Nicollet Avenue.
Whittier Clinic Type of facility: Medical clinic Location: Minneapolis Client: Hennepin County Medical Center (HCMC) Architect: HGA Architects and Engineers Engineer: HGA Contractor: McGough Construction Completion date: November 2010 Total cost: $16.5 million Square feet: 60,000 Whittier Clinic is a pedestrian-friendly family medical center that celebrates the cultural diversity of its neighborhood.The project has reinvigorated a neglected urban site just outside downtown Minneapolis, replacing an abandoned warehouse with a light-filled clinic designed to achieve LEED silver certification. The project is the first of two phases planned for the 3-acre site.The clinic provides urgent care, imaging, lab, and OT/PT services, and a physician residency program. Phase two, to be completed with city partner-
Inside, colored accents, based on HCMC’s branding logo, translate into wayfinding tools—especially important given the diversity of languages spoken by the patients. Each department entry is designated by one of the four logo colors, paired with over-scaled graphic images to facilitate wayfinding.These images and colors are combined in a two-story “feature wall” that greets patients as they enter the building and shields waiting areas from public circulation paths. Above: Windows flood the clinic building with light. Inset: Second-floor waiting space
Fairview Southdale Hospital NICU Type of facility: Hospital neonatal intensive care unit
Location: Edina, Minn. Client: Fairview Southdale Hospital Architect/Interior design: Perkins+Will Engineer: Michaud Cooley Erickson Contractor: Carlson-LaVine, Inc. Completion date: April 2011 Total cost: $1 million Square feet: 5,530 (renovation) This renovation of Fairview Southdale Hospital’s neonatal intensive care unit (NICU) involved a complete re-planning of a space that had become cramped and inefficient, with no privacy for individual families.The
renovation has more than doubled the size of the nursery while the number of bassinettes has remained approximately the same. Expanding the unit to the exterior wall offers daylight to families and staff. The new layout of the NICU provides individual areas for infants and their family. Four intake bays are located directly across from the nurse’s station for good observation of the infants during their first hours on the unit. There is one private isolation room, as well as a private room for families of twins. The lighting design reflects the design goal of providing a quiet and soothing environment to promote healing for these delicate newborns. Dimmable, indirect soffit lighting gives a soft glow to each area.This lighting is supplemented by a pendant fixture at the parent reading/sleeping area, a downlight for nurse charting at the wall-mounted computer, a dimmable exam light for procedures, and general overhead lighting for cleaning. Far left: View from the central corridor into individual patient bays Inset: Separate room for families of twins
Peter J. King Emergency Care Center Type of facility: Hospital emergency department Location: St. Paul Client: Allina Hospitals & Clinics Architect: HDR, Inc. Engineer: Michaud Cooley Erickson Contractor: McGough Construction Completion date: March 2011 Total cost: $29 million Square feet: 33,000 The new United Hospital emergency department (ED) provides important and much-needed emergency medical care capacity in the East Metro. “United Hospital faces constant, daily pressure to provide effective, fast, and affordable treatment to the community," says Dan Foley, MD, United Hospital’s vice president of medical affairs and a physician in the emergency department.“The emergency department is the main entry point for many who need urgent health care.” The project has expanded the ED from 12,000 square feet to 33,000 square feet.The new emergency department has 40 beds, compared to 20 beds in the original facility.The annual capacity will also increase, to 58,000, compared to 44,000 served in the old department. All necessary diagnostics equipment will be located in the new facility. In the old department, patients needing x-rays, ultrasound, or CT scans had to be taken elsewhere in the hospital for imaging. In case of a toxic chemical event, the new facility has a decontamination
area. Four trauma rooms are available, as well as specially designed sexual assault exam rooms and six psychiatric rooms for mental health patients. Above: Exterior rendering shows the view from Smith Avenue. Inset: Interior exam/treatment room
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PrairieCare Behavioral Health Facility Type of facility: Inpatient and outpatient clinic offering psychiatric services to children and adolescents Location: Maple Grove, Minn. Client: PrairieCare Medical Group Architect: Pope Architects, interior design/interior architecture Engineer: Egan Mechanical (design-build) Contractor: RJ Ryan Construction, Inc. Completion date: February 2011 Total cost: $6 million Square feet: 23,700
PrairieCare offers hope and healing to those suffering from psychiatric conditions. PrairieCare’s new behavioral health facility in Maple Grove provides psychiatric care for children and adolescents (ages 3 to 17). The new, single-story facility includes 20 inpatient beds, as well as an outpatient partial hospitalization program (PHP), where patients remain at home while receiving treatment. The design of the interior environment welcomes the families of patients and helps the children and young adults feel safe, supported, and at ease. Finishes, furniture, and artwork were carefully selected to enhance the experience of the children and families and promote safety and healing.The design utilizes a warm, bright color palette, maximizes natural light, and incorporates bold geometric shapes and stripes. Commissioned artwork is featured throughout the inpatient portion of the building. The new facility uses no vinyl flooring products, but instead uses low maintenance linoleum flooring within all the patient bedrooms and the remaining hard surfaced areas. Use of these materials drastically reduces VOC emissions and hospital downtime that is required with typical vinyl flooring maintenance. Above left: The hallway area features warm colors, geometric shapes, and
commissioned artwork. (Photographer: Philip Prowse Photography) Inset: Reception area in the 20-bed facility (Photographer: Philip Prowse Photography)
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St Joseph’s Area Health Services Type of facility: Hospital expansion and renovation, new clinic Location: Park Rapids, Minn. Client: Catholic Health Initiatives and Park Rapids Area Health Care Architect: HGA Architects and Engineers Engineer: HGA Contractor: Kraus-Anderson Construction Company
Completion date: January 2010 Total cost: $21 million Square feet: 51,000 (new clinic); 12,000 (new hospital); 30,000 (hospital remodel) The addition and remodeling of St. Joseph’s Medical Center integrate the existing hospital and a new clinic into a contiguous facility, situated in the Mississippi Headwaters area of northern Minnesota. Because of the one-half floor level change, the existing clinic was raised and the flat site was gradually sloped so that the new south-facing clinic and hospital entry would be accessible, adjacent to ample parking, and aligned with the existing hospital main floor level at roughly 6 feet above street level. The entry forms a two-level bridge, allowing patients and visitors immediate access to both levels of the clinic and hospital. Public circulation wraps around a central exterior courtyard that contains gardens and dining spaces.This courtyard can be viewed from all waiting areas. New and expanded diagnostic and procedure areas are located between the clinic and hospital for shared services and maximized efficiency. Several existing hospital inpatient and procedure areas were remodeled, the clinic was horizontally expanded, and much of the campus infrastructure was replaced or upgraded. To capture the feel of the North Woods lake region, the architecture utilizes local lumber, stone, and landscaping. Economical, efficient indirect lighting enhances the warmth of the natural materials found in the regional architecture.
Above: Local building materials combine with natural lighting to capture the feel of the North Woods lake area. Inset: Visitors entering the facility are shielded from the elements by the entrance canopy.
Healthcare Planning and Design
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Fridley Medical Center Type of facility: Multi-tenant medical center
Location: Fridley, Minn. Client: Premier FMC, LLC Architect: Amcon Construction Interior design: Amcon Construction (common areas, Multicare Associates clinic and corporate offices, MultiCenter Physical Therapy, Goodrich Pharmacy); BDH&Young (Minnesota Oncology and VPCI tenant spaces); WCL Associates (MAPS Medical Pain Clinics) Engineers: Carlson Professional Services Inc., civil;Anderson-Urlacher, structural Contractor: Amcon Construction Completion date: October 2010 Total cost: $14 million Square feet: 60,000 Located on Allina’s Unity Hospital campus, Fridley Medical Center is a new, two-story medical office building that provides expanded facilities for Multicare Associates’ primary care and specialty clinic. Other tenants in the center include the Virginia Piper Cancer Institute–Unity Hospital and Minnesota Oncology, Goodrich Pharmacy, Top: Exterior of the multi-tenant facility Top inset left: In the facility’s main lobby, stone and wood are complemented by organic patterns that add texture not typically seen in medical offices. Top inset right: A climate-controlled skyway connects to the Unity Professional Building and Unity Hospital, allowing patients, staff, and visitors a convenient route to and from Unity Hospital, Unity Professional Building, and Fridley Medical Center without going outside. Left: In the Minnesota Oncology reception area, a combination of warm wood tones, decorative lighting, and unique materials provides a comfortable and cozy atmosphere for patients and staff. Below: Glass dividers embedded with real grass help create a natural, organic environment in the lobby of Multicare Associates.
MAPS Medical Pain Clinics, and MultiCenter Physical Therapy. As noted above, several tenants hired their own interior designers, to fashion spaces that meet the unique needs of their patients. The facility was designed with the understanding that health care environments can greatly affect clinical outcomes and patient, family, and caregiver experience and mood. Special attention was given to using daylighting, earth tones, textures, and natural materials, including wood and stone, to create a soothing, therapeutic environment that reduces stress and provides comfort to patients and staff alike.Additional notable features include a wellness walk and skyway connecting Fridley Medical Center to the Unity Professional Building and Unity Hospital. “It is our mission and vision to deliver high quality, multispecialty care that is convenient and accessible to our patients. In addition to expanding Multicare, this new building was designed to offer a variety of comprehensive medical services to meet the needs of the communities we serve,” says Jeanine Schlottman, chief executive officer of Multicare Associates.
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Good Samaritan Society-Albert Lea Type of facility: Recovery/Skilled nursing Location: Albert Lea, Minn. Client: Good Samaritan Society Architect: Horty Elving Engineer: Horty Elving Contractor: Joseph Company, Inc. Completion date: Summer 2010 Total cost: $1.1 million Square feet: 11,000 This project renovated an existing 1974 nursing home to create Recovery Trail, the campusâ&#x20AC;&#x2122; new transitional care unit. Recovery Trail is designed to serve those who need short-term rehabilitative or skilled care following illness, hospitalization, or surgery. The project remodeled an existing wing of the building, with private and semi-private resident rooms with half-bathrooms (sink and toilet only). Reflecting the neighborhood concept of design, which is more supportive of resident-centered care, the final design has 18 private rooms, each with a private full bathroom, including European-style showers, sinks, and toilets.The common living areas for the staff and residents consist of a home-like kitchen that opens into an 18-seat dining area, a spacious sitting room with a fireplace, and an activity space.The original nurse station was replaced with a large nurse charting room that provides better functionality for the staff, as well as a
medications room.Two staff offices and a conference room are being added in the remodeled area. Each rehabilitation suite has been designed to provide guests with amenities more evocative of a hotel than a nursing home.The common areas include a kitchen and dining area with two separate living rooms, outdoor courtyards, and patios. Top: The common living areas include a spacious sitting room for residents. Left: Each of the 18 private rooms includes a private full bathroom.
Solutions for the Changing Healthcare Environment
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JUNE 2011
t: 612.851.5070 f: 612.851.5001 e: rick.hintz@perkinswill.com www.perkinswill.com MINNESOTA PHYSICIAN
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The Triple Aim of the Institute for Healthcare Improvement comprises three main goals: better
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Condensed schedule, expanded facilities Focus of hospital project is enhancing patient experience
care for individuals, better health for populations,
By Michael Hagen and Don Rolf
and lower per capita costs. The three health care design projects featured in this month’s issue discuss the different strategies they used to accomplish the Triple Aim goals in projects serving specific populations: residents of long-term care centers; hospital inpatients in rural Minnesota; and people being treated in behavioral health facilities.
W
ith any health care facility design, it pays to take a progressive approach that can accommodate changes. When Riverwood Healthcare Center replaced its outdated 1950s hospital with a modern, integrated clinic and hospital facility in 2003, one thing was certain: There had to be room to grow. Located on a new, 11-acre site on the outer northeast edge of Aitkin, about a mile from the original hospital, Riverwood’s design has facilitated seamless expansion with several additions. To accommodate a growing number of specialty physicians seeing patients in Aitkin,
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Riverwood expanded its specialty clinic in 2006. The 7,000square-foot addition included 20 exam rooms, several special treatment rooms, and six workstations for physicians. As physicians expressed a need for a permanent magnetic resonance imaging (MRI) machine for more timely and convenient diagnosing and treatment of medical conditions, the organization enlarged its radiology department, adding an MRI suite in 2009. Now Riverwood is embarking on a $21 million hospital expansion project to enhance the patient hospital care experience and streamline patient care areas. The size of the integrated hospital and clinic will grow by 36 percent, from 87,800 to 137,570 square feet. Physician input is again playing a key role in expansion and renovation of the inpatient, rehabilitation, and surgery departments. Funding accelerates project
In 2010, Riverwood applied for and was the only Minnesota hospital to receive a low-interest loan for $12 million through the Rural Development Community Facility Funding program funded by the U.S. Department of Agriculture. AgStar Financial is contributing an additional $4 million in permanent financing for the project. The $5 million gap in funding will come from Riverwood resources, including private contributions raised by Riverwood Foundation, which total nearly $1.2 million to date. With funding secured, HDR Architecture helped Riverwood collapse its five-phase master facility plan, originally projected to be implemented over 10 years or more, to 18 months. By combining the architectural and construction work into a shorter
time span, the health system will save about $6 million. Enhancing patient care capacity, safety
The centerpiece of Riverwood’s expansion is converting its inpatient area, which currently has semi-private rooms and 24 beds, to 25 private patient rooms— the maximum number allowed for critical access hospitals. Fourteen new hospital patient rooms will be built on the west side of the hospital, and the 11 existing semi-private rooms will be retrofitted to look exactly like the newly built ones. The industry standard for hospitals is moving to private patient rooms, with good reason. Private rooms make it much easier for physicians to communicate confidentially with patients and family members on sensitive health issues. They also enhance infection control and make it easier to examine patients. Private rooms will also increase Riverwood’s capacity for patient care, keeping patients closer to home. With semi-private rooms, the hospital is often “full” with 16 to 17 patients because of infection control, gender, or other issues that prevent room sharing. When this occurs, patients are transferred to out-of-area hospitals, creating a hardship for rural community members where driving distance can be an obstacle to visiting a hospitalized family member. Riverwood relied on health care industry research and input from HDR senior nurse consultant Barbara Pille, who has 40 years of work experience in health care facilities and is accredited and certified in evidence-based design, to guide the design of the new inpatient area. The “Transforming Care at the Bedside” research study completed by the Institute for Healthcare Improvement (IHI) found that increasing the amount of time nurses spend at a hospital patient’s bedside greatly improves the quality of care for patients. Pilot IHI projects have shown a reduction in patient falls and length of stay as well as improved medication monitoring and better pain management.
To keep nurses closer to their patients, Riverwood’s new design calls for nurse viewing stations to be built between every two hospital patient rooms. The stations allow nurses to do their care documentation while being able to view patients in their rooms, only a few steps away. Nurses will also be able to access supplies such as gloves, gowns, and needles in decentralized areas in the hallways close to patient rooms, eliminating time spent hunting down supplies. Another aspect of improving hospital patient care is establishing zones of care—for patients, visitors, and clinical care providers. Visitors will have an area around a sofa sleeper located by the window. This will keep the space around the hospital bed clear for clinical care. The patient’s space—the bed—will have controls for lighting, window shades, and communication devices. Noise reduction afforded by private rooms and carpeted hallways will also enhance patient healing at Riverwood. Research shows that patients eat and sleep better when they are cared for in a quiet, calm environment. With patient and staff safety as a guiding principle in the new inpatient area, Riverwood will install 13 permanent ceiling lifts to replace several mobile ones now being used. Patients often feel more comfortable with a secure lift system, and nurses are more likely to use lifts that are readily available, reducing the potential for occupational injuries. In the redesigned space, the flow of the inpatient wing will be very efficient and compact. The pharmacy will relocate to be closer to the inpatient area. The rehabilitation department, also adjacent to the inpatient care area, is being enlarged and reconfigured to better support orthopedic care. Orthopedic surgeons who practice at Riverwood influenced the design of the rehabilitation space to support a new practice model for patient care. Upon completion of the renovation, orthopedic surgeons will see patients in exam rooms within the rehabilitation depart-
ment. Putting orthopedic specialists and physical therapists in close proximity supports a higher level of teamwork in delivering patient care. Within the inpatient area, both the intensive care unit and the birthing suites will relocate and grow larger. A third labor, delivery, recovery, and postpartum room will be added and the area enclosed for more privacy for patients and family members. The intensive care unit, which is being designed with greater flexibility to meet the needs of both patients and the hospital, will include four beds and a more spacious nursing station. An added 31,360-square-foot administrative wing is designed to bring all Riverwood employees in Aitkin together in one location. This will create efficiencies by eliminating travel time between facilities for meetings and other business. This new two-story wing will house services and staff for administration, billing, education, finance, foundation, human resources, information technology and a computer lab, marketing, medical records, and quality/compliance. For future growth needs, this wing is designed to allow the addition of a third story. Streamlining patient care areas
A new infusion therapy addition, to be built adjacent to the emergency room, will enhance care for chemotherapy and other patients needing infusion medication therapies. Its five patient bays will replace three existing bays now located in cramped quarters. Patients will gain more privacy and a designated entrance just off the parking lot that bypasses the main lobby. The project includes the renovation of about 24,000 square feet of existing space to streamline patient care. Respiratory therapy will relocate closer to the clinic to free up space for surgery. The surgery department will undergo a major renovation to accommodate advanced technology, enlarge the waiting room lobby, and add two consultation rooms for surgeons to meet with patients and family members.
Diabetes education and wound care, which are now offered a few blocks from the hospital, will move to the hospital, close to the family practice clinic, concentrating all outpatient services in one area. The proximity of wound care to the family practice clinic will make it easy for physicians to stop in for a quick consultation with the wound care nurse and patient as needed. Tapping natural design elements
Riverwood is working with Kraus-Anderson on the construction of its hospital expansion. The project will proceed in phases, with building taking place in multiple locations simultaneously, behind temporary barriers. Hospital operations will be able to proceed smoothly during the construction period. The end result of the Riverwood hospital expansion will be a less institutional look and feel, with warm earth tones—purple, brown, tan, and
green—on the walls and floor coverings. More daylight will illuminate hallways and patient rooms. Best of all, a landscaped courtyard will provide an inviting outdoor space for patients, family members, and employees. Construction began in May 2011, and Riverwood’s newly renovated hospital is slated for completion in December 2012. Collapsing the master facility plan phases and construction of multiple additions and renovations into a compressed time period was a significant challenge, but the benefits will pay off for years to come—both for Riverwood hospital patients and for the health system’s bottom line. Michael Hagen is chief executive officer for Riverwood Healthcare Center, an integrated hospital and clinic health system based in Aitkin, Minnesota. Don Rolf is project manager for HDR Architecture, the firm that has guided the design for the renovation of Riverwood’s health care facilities since 2006. HDR has more than 65 accredited members and is partnered with the Center for Health Design.
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T
he scene described in the news story about patients presenting with mental health problems painted a grim picture: “One recent Monday afternoon, more than 40 doctors and nurses were rushing back and forth with clipboards and stethoscopes, rolling patients on gurneys and tending to those parked in the narrow hallways. Phones were ringing off the hook, the loudspeaker was barking pages for physicians, and medical monitors were beeping incessantly. There was no natural light—only the yellow glow of fluorescent lights overhead.” The National Public Radio story, which aired in April, is a familiar one. Instead of presenting to a facility or space designed to accommodate patients suffering from mental health and substance abuse issues, these patients are presenting in emergency departments, spaces ill-equipped to effectively and humanely handle such cases. One emergency room physician described the ER, with its 24/7 activity and jarring noises, as more like Las Vegas than a place
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Rethinking mental health care facilities Using design to reduce stigma By Brian B. Buchholz, AIA, ACHA, CID; Rick Dahl, AIA; and Don Thomas, CID of healing. It’s certainly the wrong place for someone in the midst of a psychiatric crisis. But the issue isn’t simply about emergency rooms accommodating mental health patients. Mental health care has long been an underfunded and underserved segment of our health care delivery system. From reimbursement disparities to social stigma, spaces for mental health illness have lagged in comfort and support when compared to other health care spaces. Evidence-based design for care spaces has deinstitutionalized the delivery of care in ambulatory centers, obstetrics, pediatrics, and medical-surgical
Occupational Medicine Family Medicine Internal Medicine Pediatrics & Adolescent Medicine Hospitalist Program
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units, where hospitality and comfort now go hand-in-hand with efficiency and safety. However, in mental health facilities, the lack of investment has left their institutional environments intact. In the worst cases, mental health treatment has remained in the oldest and bleakest facilities on campus, reflecting the stripped-down nature of state-provided services. As state and federal budgets have shrunk, even these spaces have disappeared, leaving emergency departments to triage patients until beds in other facilities are found. Opportunities for change
In 2006, Avera McKennan Hospital made a bold statement about mental health services. Avera Behavioral Health Center opened in Sioux Falls, S.D., as the first freestanding behavioral health facility to be built west of the Mississippi River in 15 years. With a lobby featuring skylights, stained glass, stone, and water features that evoke the natural environment of the Upper Midwest, it is a dramatic departure from the historically institutional look of mental health facilities. Its effect on patients was immediate. On the day Avera moved people into the new center, a male adult patient explored the new unit and his room. His eyes filled with tears. When asked what was wrong, he responded, “Nothing … I have never been in a place this nice in my life.” Research into the effects the environment can have on the health and healing of patients has been definitive: Create an environment that encourages health and wellness, and patients will respond. As the Institute of Medicine (IOM) noted in its Quality Chasm
Series, Improving the Quality of Health Care for Mental and Substance-Use Conditions, the approach to designing for mental health care should be no different. Among the rules to redesign health care are: • Care based on continuous healing relationships • Customization based on patient needs and values • Evidenced-based decisionmaking • Safety as a system priority • Anticipation of needs At the same time that our understanding of the relationship of physical space to healing environments is growing, so too is our understanding of the relationship between physical and mental health. A study conducted by the Centers for Disease Control and Prevention in 2007 found that chronic diseases like cardiovascular disease, diabetes, and asthma, and risk factors such as obesity, smoking, physical inactivity, and heavy drinking were all significantly associated with current depression and a lifetime diagnosis of anxiety or depression. A poster presentation at the American Psychiatric Association’s 59th Institute on Psychiatric Services noted that there is a strong association of mental illness with chronic diseases and related adverse behaviors, suggesting a need to employ an integrated, multidimensional approach to health care. Changing approaches to change attitudes
It’s not that the buildings themselves are going to transform the attitude about mental health care treatment. However, past building practices have made it easy to stigmatize mental health illness and treatment. Relegated to less-than-prime space, separated facilities, or behind locked doors in larger facilities, the segregation—even if the strategy is intended to protect patient safety and privacy—reinforces the notion that mental illness is something to fear or to feel ashamed of suffering. Putting the treatment of mental illness prominently in the community changes the conversations about the illness. MENTAL HEALTH to page 34
Associate Medical Director
RiverSource Life Insurance Company For the physician who is intrigued by the idea of leveraging their clinical experience in a non-clinical career. Roles & Responsibilities:
• Provide mortality and morbidity risk assessment opinions on case referrals from underwriting. • Interpret electrocardiograms, treadmills, chest x-rays obtained as underwriting requirements. • Interact with underwriters and other insurance professionals within the company • Provide training to underwriters, both on an individual basis and in the classroom setting. • Stay current with latest medical treatments, diagnostic testing • Begin the course work necessary for Board Certification in Insurance Medicine, including LOMA or CLU courses
Education & Experience:
• Doctor of Medicine or Doctor of Osteopathy degree • Current license to practice medicine in good standing • Residency completed; Board Certification in Internal Medicine, Internal Medicine/ Pediatrics, or Family Practice background preferred • Minimum of three years of clinical experience beyond residency • Public speaking experience a plus but not a requirement • Ability to travel
Overview:
The position of Associate Medical Director with RiverSource Life Insurance Company (an Ameriprise Financial company) provides a singular opportunity for primary care physicians who enjoy the intellectual aspects of medicine, would like a challenging and stimulating career but are interested in leveraging their clinical skills in a non-clinical career. This unique position reports to the Chief Medical Director and provides on the job mentoring to help facilitate the transformation of clinical skills into those necessary for the practice of Insurance Medicine. It provides the clinician an opportunity to do so in a gradual fashion, allowing the practicing physician to work on a part time basis while building their new skill set. Insurance Medicine requires knowledge in the fundamentals of mortality and morbidity risk selection, the ability to analyze how medical disorders and diseases impact risk selection, as well as superior skills in the interpretation of electrocardiogram and stress tests. Other areas developed through on-the-job training and self-study are product design, life insurance company operations, and reinsurance functions. In the US, there are about 500 doctors practicing Insurance Medicine in the life and disability fields. Beginning salaries vary and corporate benefit packages can add 25-30% or more to total compensation. While a career in Insurance Medicine does not involve direct patient care, it provides an intellectually stimulating job where a physician is able to evaluate the risk presented by a spectrum of unusual diseases and disorders that they may never have had the opportunity to see in practice. Busy clinicians may not have the time to read and research a potential disease in a patient; in this job it is what we do every day while enjoying the benefits of a less stressful lifestyle without evening, holiday and weekend call. The Associate Medical Director position is initially a part time position consisting of one or two half-days per week, with the potential of full time employment and expansion of responsibilities for those individuals who are interested and excel. The ultimate goal is to obtain Board Certification in Insurance Medicine, a field recognized by the AMA. The coursework required to obtain certification is fully supported by RiverSource Life Insurance Company.
Take the next step Call or email Lisa Arnold (612) 678.6734 lisa.f.arnold@ampf.com
Brokerage, investment and financial advisory services are made available through Ameriprise Financial Services, Inc. Member FINRA and SIPC. Some products and services may not be available in all jurisdictions or to all clients. Ameriprise Financial Services, Inc., is an Equal Opportunity Employer. © 2011 Ameriprise Financial, Inc. All rights reserved.
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MINNESOTA PHYSICIAN
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Wrapping a nurses’ station into the entry of an inpatient unit places the emphasis of the space more on the patient group areas and creates a comfortable space for patients, yet still provides staff visibility and control of the unit.
Mental health from page 32 Brock Nelson, chief executive officer and president of Regions Hospital, notes that his organization’s new eight-story mental health care facility demonstrates that the level of care to be provide for mental health will be equal to the level of care provided for other illnesses. While stand-alone mental health facilities are rare, design solutions in a facility such as Avera Behavioral Health show how space can transform both
the delivery of and attitudes toward mental health care. Even entrances can make a statement, to patients and to the community, that mental health care is about healing and optimism, not shame and embarrassment. That message can be conveyed boldly, from exterior aesthetics that are transparent, personable, and welcoming, using materials like wood and stone, to an interior design where skylights and warm materials and colors cre-
Together we will Riverwood Healthcare Center, a 24-bed critical access hospital with three full service clinics in Aitkin, MN has an opportunity for a BE/BC Family Medicine Physician with OB. Imagine a “morning commute” that takes you past sparkling lakes and through the beautiful north woods….the ideal practice setting where your professional aspirations come together with the quality of life you are looking for. • 4 day work week • Quick and easy ramp up of practice • Call is 1:8 weekdays and 1:10 weekends • No required ER shifts • 80% outpatient • Sub specialty support from 23 specialties and 37 physicians • $50,000 sign-on bonus available • Student loan forgiveness Riverwood is the first rural hospital in Minnesota to be certified as both a Level III Trauma Center and a Comprehensive Advanced Life Support Hospital. Riverwood ranks as the #2 hospital in the state for joint replacements. We invite you to come enjoy the peacefulness of a quaint, small town immersed in the energy of a growing and vibrant community. You care for the lives of others…come work in a place that cares for you! Please contact Tanya Pietz, Physician Recruitment Direct: 218-927-5587 Email: tpietz@riverwoodhealthcare.org www.RiverwoodHealthcare.com AA/EOE
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MINNESOTA PHYSICIAN JUNE 2011
As the debate about the quality of care for people with mental illness becomes more public, solutions for spaces and facilities can influence that discussion by demonstrating that treatment for mental illness is nothing to hide or feel ashamed of seeking. ate a non-threatening environment for patients, families, and staff. Although patient safety remains an important element in the design of new treatment spaces, bringing dignity to the forefront changes the approach to designing solutions that benefit patients and staff. The elements that create a non-threatening entry to the space, including natural light and calming colors, can be carried through to the inpatient units. Nurses’ sta-
Orthopaedic Surgery Opportunity Live in Beautiful Minnesota Resort Community
tions at unit entries that wrap into units give staff visibility and control while keeping the emphasis of the space on the group areas for patients. Just as private rooms improve the healing environment and thus have become standard practice in designing health units, elements that give patients in mental health units a sense of privacy and control also encourage healing. From personal vanities to entry threshMENTAL HEALTH to page 36
Two BC/BE Orthopaedic Surgeons wanted to join four orthopaedic surgeons at Sanford Bemidji Orthopaedics Clinic in Bemidji, Minnesota. Part of an 85-physician, multi-specialty group practice and 118 bed acute care hospital. 1:6 call anticipated. Competitive compensation/benefits package, paid malpractice, relocation assistance and more. Sanford Health of Northern Minnesota has 1,450+employees and is part of Sanford Health system based in Fargo, ND and Sioux Falls, SD. Bemidji, Minnesota, located in northwestern Minnesota, is a beautiful resort community offering exceptional schools, a state university, and yearround cultural activity as well as great access to the outdoors for year-round recreation activity. To learn more about this excellent practice opportunity contact: Kathie Lee, Director Physician Placement Phone: 701-280-4887 Fax: 701-280-4136 Email: Kathie.Lee@sanfordhealth.org AA/EOE
Myy dedication dication preserves pr eser s ves our ccommunity. ommunityy. We iinvite We nvite you you to to eexplore xplore our opportunities opport rtunities iin: n: our
Medical M edical Director Director Metropolitan Health Plan Metropolitan Plan (MHP), P), a state state cer certified tified HMO HMO,, seeks a Medical Medical dical Director Dir ector to to lead strategic strategic medical ical management initiatives initiatives and serve serve as partner. a kkey ey business par tner. Position Position n requires requires a MN license, license, experience experience in na caree setting setting,, knowledge medical leadership rrole ole in a HMO MO or managed car knowledge dge statee rregulations cross of ffederal ederal and stat egulationss and the ability ability tto o lead cr oss functional functional onal tteams eams to to implement management ment initiatives. initiatives. County Hennepin C ounty is a vibrant blend of 46 municipalities that includess cityy of M Minneapolis the cit inneapolis (known (known as the â&#x20AC;&#x153;City â&#x20AC;&#x153;City of Lakesâ&#x20AC;?), Lakesâ&#x20AC;?), attractive attractive suburbs, suburrbs, Minneapolis and peaceful small ttown own settings. settings ngs. M inneapolis was recently recently named d Americaâ&#x20AC;&#x2122;s one of Amer icaâ&#x20AC;&#x2122;s Best Cities for forr the Outdoors Outdoors by by Forbes Forbes magazine â&#x20AC;&#x201C; extensive qualityy commended especially ffor or its ex tensive parklands parklands and healthy healthy air qualit (May (M ay 15, 2009). To To view view complete complete posting and apply online, online, visit:
www.hennepin.jobs w ww.hennepin.job .jobs Strong S trong car careers. eers. S Strong trong ccommunities. ommunities. Recruiter R ecruiter Contact: Contact: LLeanne.Rajtar@co.hennepin.mn.us eanne.Rajtar@co ar@co.hennepin.mn.us
In the heart of the Cuyuna una Lakes region of Minnesota, the medical cal campus in Crosby includes Central Lakes kes Medical Clinic, a 30-physician multispecialty cialty group and Cuyuna Regional Medical Center, a critical access hospital offering superb s new ffacilities acilities with with the the llatest atest medical medical ttechnologies. echnologies. Outdoor activities abound, andd with the T i Cities metropolitan Twin t litan area just justt a short h t drive away, you can experience the perfect bbalance alance of of rrecreational ecreational and and ccultural ultural activities. activities. EEnhance nhance your your pprofessional rofessional life life in in aann eenvironment nvironment that that pprovides rovides exciting exciting practice practice Northwoodâ&#x20AC;&#x2122;s oopportunities pportunities iinn a beautiful beautiful N orthwoodâ&#x20AC;&#x2122;s ssetting. etting. welcomes TThe he Cuyuna Cuyuna Lakes Lakes rregion egion w elcomes you. you.
s &AMILY -EDICINE s )NTERNAL -EDICINE
CENTRAL C ENTRAL LAKES L AKES MEDICAL M EDICAL CLINIC CLINIC P.A. P .A .A.
Contact: Todd Bymark, mark, tbymark@cuyunamed.org (866) 270-0043 / (218) 546-4322 | www.cuyunamed.org org
Allina Hospitals & Clinics in Minnesota/Western Wisconsin
Look for the friendly doctor in a MN based physician staffing service ...
Physicians: â&#x20AC;˘ Let us do your scheduling & credentialing â&#x20AC;˘ Paid Malpractice â&#x20AC;˘ Physician Friendly â&#x20AC;˘ Choose where and when you want to work â&#x20AC;˘ Competitve Rates â&#x20AC;˘ Courteous Staff
Clients: â&#x20AC;˘ Prevent loss of revenue â&#x20AC;˘ BC/BE physicians â&#x20AC;˘ Competitive rates â&#x20AC;˘ Quality coverage â&#x20AC;˘ Malpractice coverage paid by us
P-763-682-5906/F-763-684-0243 michelle@whitesellmedstaff.com www.whitesellmedstaff.com
Allina Hospitals & Clinics is known for its clinical quality, and an award-winning EMR. At Allina, physician leadership and involvement drive our success. The Clinic and Community Division features the Allina Medical Clinic, Aspen Medical Group, and Quello Clinics, as well as Home and Community Services. Our clinics, as well as our 11 hospitals, are located in the Twin Cities metro area, throughout Minnesota, and in western Wisconsin.
Full- or part-time urban, suburban, and rural openings are available in the following specialties: t "MMFSHZ t %FSNBUPMPHZ t %JTUSJDU .FEJDBM %JSFDUPS t &NFSHFODZ .FEJDJOF t &OEPDSJOPMPHZ t 'BNJMZ .FEJDJOF t (FOFSBM 4VSHFSZ t (FSJBUSJDT JODMVEJOH .FEJDBM %JSFDUPS
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Allina offers a competitive benefits and salary package. For more information, please contact: Kaitlin Osborn Allina Physician Recruitment Toll-free: 1-800-248-4921 Email: Kaitlin.Osborn@allina.com Fax: 612-262-4163 Website: allina.com/physiciancareers EOE
11-8253 Š2011 ALLINA HEALTH SYSTEM. ŽA REGISTERED TRADEMARK OF ALLINA HEALTH SYSTEM
JUNE 2011
MINNESOTA PHYSICIAN
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Mental health from page 34 olds that patients pass through between their rooms and community areas, the design aims to give patients a sense of respect and control in an environment that is safe for them and for staff. Large, open, daylit common rooms also promote interactions among patients and between patients and staff. Circular rooms for group therapy sessions communicate a sense of parity among patients and providers, reducing the threatening image of authority that more hierarchical, formal arrangements may present. Safety remains a top priority, and elements such as high, secured ceilings to eliminate contraband and vandalism, door-swing overrides to eliminate the potential for barricades, and nonbreakable glass partitions are key design elements. However, these can be incorporated in a fashion that makes the space feel comfortable and personable. Similarly, unobtrusive passive digital monitoring improves the prevalence of
secure measures without making it evident. At Avera Behavioral, a unique design solution uses parallel corridors with transitional rooms to separate operational and support services from patient areas and establish a new protocol for privacy, dignity, confidentiality, and security. The rooms provide a secure and graceful entrance to inpatient units, reducing the fear historically associated with locked entry doors. The zone also allows support staff to serve the facility without walking into a unit. Finally, the rooms offer private space for family visitation and physician consultation. In addition, spaces have to respond to the increasing levels of acuity and complexity that patients present. The location of nursing units, emergency departments, and psychiatric clinics is an important factor in serving both patients and staff efficiently and effectively. Proximity to medical office spaces also improves the connections between outpatient and inpatient services and creates a
more efficient work environment for care providers traveling between settings. A future of possibilities
In 2010, Congress passed the Mental Health Parity Act, which requires group health plans and insurers to ensure that health policy limitations applicable to mental health and substance use disorder benefits are no more restrictive than the predominant requirements or limitations applied to substantially all medical-surgical benefits. Under the Affordable Care Act, patientcentered medical homes also must provide timely, comprehensive care, including care for chronic conditions that begin with mental health/substance abuse disorders. States are instructed to address mental health/substance abuse services regardless of which conditions are selected for focus. According to the Agency for Healthcare Research and Quality, nearly 12 million of the 95 million annual visits to emergency departments are related to mental health disorders
Come home.
Excellent practice opportunities exist in family-oriented communities that offer year-round outdoor activities, cultural events, and superior education districts that will allow you to balance your work & life. Our employment model features competitive salaries, a comprehensive benefits package, paid malpractice insurance, and a generous relocation allowance. Contact: Jean Keller Physician Recruiter Phone: (701) 280-4853 Jean.Keller@sanfordhealth.org
Brian B. Buchholz, AIA, ACHA, CID, and Rick Dahl, AIA, both licensed architects, and Don Thomas, CID, a certified interior designer, are principals at BWBR, a St. Paul-based design solutions firm with practices in architecture, interior design, and master and strategic planning. Buchholz is also a member of the American College of Healthcare Architects.
NEW POSITIONS:
Where organizational strength lies in the diversity of people who call SANFORD HEALTH – home. Sanford Health – Fargo Region is redefining health care. Serving northwestern Minnesota and eastern North Dakota, we offer innovative technology, support of a multi-specialty organization, and dependable colleagues.
and/or substance abuse. The high costs and limited effectiveness associated with using the nation’s existing emergency departments as our mental health treatment spaces are unsustainable. As states and the nation reassess the way we deliver care and allocate space to take advantage of economies and efficiencies, we can’t afford to continue segregating or eliminating behavioral health care spaces from the nation’s health care system. Improving the way people with mental illnesses are cared for, throughout the health care delivery system, offers the ability to serve entire communities better.
Cardiology Dermatology ENT Emergency Medicine Family Medicine Gastroenterology Hospitalists Internal Medicine Neurology Occupational Medicine Oncology Orthopedic Surgery Pediatric Specialties Psychiatry Pulmonology (Sleep) Rheumatology Urology
Family Practice Urgent Care Dynamic, independent 3 location, single-specialty practice in northwest Minneapolis suburbs is seeking additional associates for its Rogers site and has Full Time/ Part Time shifts in the Crystal and Rogers Urgent Care. • • • • •
Partnership opportunity after 2 years Competitive salary with incentives Excellent benefits, 401k/employer paid pension Practice at one site/one hospital Physician-owned
Please contact or fax CV to: Joel Sagedahl, M.D. 1495 Highway 101 North, Plymouth, MN 55447 763-504-6600 • Fax 763-504-6622
Visit our website at www.NWFPC.com
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MINNESOTA PHYSICIAN JUNE 2011
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fair view.org /physicians fairview.org/physicians TTTY T Y 612-672-7300 612- 672-730 0 EEEO/AA EO/A A Employer E m p l oye r
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Caring for mind, body and spirit. Mille Lacs Health System is seeking a Family Physician to join their rural practice on the southern tip of Lake Mille Lacs in Onamia, Minnesota. Our 7 Family Physicians, 8 PAs, and a Gen Surgeon provide a unique rural health opportunity with 4 outreach clinics, a 25-bed Critical Access Hospital, and attached Geriatric Psych Unit and LTC facility. We also provide services to the Mille Lacs Band of Ojibwe. Minimum qualifications: Must have an MD/DO in medicine from an accredited school and be licensed to practice in the state of Minnesota.
• ER is staffed 24/7 by skilled PAs • OB is required; C-section training is a bonus • Guaranteed competitive salary Mille Lacs Health System is an integrated healthcare organization that tends to the lifelong healthcare needs of all its patients. Come live where there is excellent hunting, fishing, and cross-country skiing. Practice medicine where your skills and experience can be fully utilized, and where you can make a difference.
Please send inquiries to; Rob Stiles; 320-532-2606 rstiles@mlhealth.org or Dr. Tom Bracken; tbracken@mlhealth.org ONAMIA • ISLE • HILLMAN • GARRISON • MILACA
Sioux Falls VA Medical Center “A Hospital for Heroes” 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. They all come together at the Sioux Falls VA Medical Center.
• Pulmonologist • Orthopedic Surgeon • Oncologist
To be a part of our proud tradition, contact:
Human Resources Mgmt. Service P O Box 5046 Sioux Falls SD 57117 605-333-6852
www.siouxfalls.va.gov JUNE 2011
MINNESOTA PHYSICIAN
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ORTHOPEDICS
M
illions of visits were made to clinics in 2005 because of foot and ankle problems, according to the National Center for Health Statistics. Ankle injuries affect people of all ages and health status, whether or not they are physically active. This article describes common reasons patients seek care for ankle injuries, treatment choices, and advances in care.
Lateral ankle sprain
By far the most common ankle injury presentation is a lateral ankle sprain. According to the American Academy of Orthopaedic Surgeons (AAOS), every day about 25,000 people sprain an ankle. About 90 percent involve a lateral ligament. The AAOS notes that ankle sprains are categorized by three grades of severity. • Grade 1 sprain: Slight stretching and some damage to the fibers (fibrils) of the ligament. • Grade 2 sprain: Partial tearing of the ligament. If the ankle joint is examined and moved
Ankle injuries Advances add to treatment mainstays By Sumner McAllister, MD in certain ways, abnormal looseness (laxity) of the ankle joint occurs. • Grade 3 sprain: Complete tear of the ligament. If the examiner pulls or pushes on the ankle joint in certain move-
sprains may require a splint or immobilization device. Rehabilitation helps decrease pain and swelling; restore range of motion, strength, and flexibility; and prevent chronic problems.
Advances in treating ankle and foot injuries include arthroscopy, tissue engineering, and targeted pain relief. ments, gross instability occurs. Most sprains heal with time and protection. Surgery is rarely needed, even for a grade 3 sprain, if it is properly immobilized. Treatment following RICE guidelines (rest, ice, compression, elevation) is advised for grade 1 and 2 sprains. Grade 3
Physician-owned multi-specialty group is seeking additional BC/BE pediatricians to meet an increasing demand. Join 7 others in a firmly established practice with a huge built-in referral base. A Call rotation of 1:8 and greater with the addition of new providers is supported by a 24-hour, nurse triage phone-line. You'll see 20-30 outpatients/day, and an average of 1-3 inpatients/day. Service lines that support our group include our own lab, sleep center, nuclear medicine, Medicare Certified endoscopic center and radiology department with a 128 slice CT and co-ownership in an ambulatory surgery center. Opportunity highlights: • Market competitive compensation guarantee to start, followed by RVU based production income thereafter • Fully integrated Allscripts electronic medical record • 35 PTO / CME Days + paid holidays; generous CME allowance • Practice connects to a regional, 270 bed, not-for-profit Mayo-affiliated hospital, Level 3 Trauma Center • State university with 14k students; 150 undergraduate / 100 graduate / 4 PhD programs; 1800 Faculty / Staff • Named one of America’s Promise “100 of the Best Places for Youth”
Besides ice and nonsteroidal anti-inflammatory drugs (NSAIDs), physical therapy modalities such as ultrasound and electrical stimulation may help reduce pain and swelling. Proprioception training may help prevent reinjury or chronic joint instability.
Medial ankle sprain
Spraining deltoid ligaments is rare because these ligaments are stronger than lateral ligaments and because the fibula tends to prevent the ankle from over-stretching that ligament. Spraining a deltoid ligament, called a medial ankle sprain, often also involves a fractured fibula or other ankle bone. That’s why x-rays are recommended with moderate to severe medial sprains. With no fracture, treatment for a medial sprain mirrors treatment for a lateral sprain, but recovery may take twice as long. Extensor tendonitis
Patients presenting with dorsal foot pain with diffuse swelling and pain when the extensor tendons are passively stretched may have extensor tendonitis. The tibialis anterior tendon is most often affected. Athletes who run, hike, ski, or bike often experience extensor tendonitis. To help prevent recurrence, patients should wear shoes that fit properly and not tie their shoelaces ANKLE to page 40
Full and Part-Time Psychiatry Positions Available! Nystrom & Associates, Ltd. is a well established, rapidly growing, independent mental health group providing outpatient mental health, chemical dependency and community based services to all ages and populations. Nystrom & Associates, Ltd. is licensed as a Rule 29 and Rule 31 clinic and has six locations throughout the State of Minnesota. Currently, we are looking for collaborative, skilled clinicians (MD, DO, CNS, NP, PA) to provide quality psychiatric care to our patients in a part-time or full-time capacity. Openings are available at the following locations: New Brighton Eden Prairie Brainerd/Baxter Apple Valley Otsego/Elk River Duluth This opportunity is strictly office based outpatient psychiatric work only. There are no weekend hours, inpatient duties or call.
• Essential retail in the community; Target, Best Buy, Lowe’s, Sears, Old Navy • Affordable housing: 4-bed, 4.5 bath, 3,572 Sq/Ft. home - $264,900 • 50 miles of local, paved trails / hundreds of acres of community parks Contact Dennis Davito, Director of Physician Placement, Mankato Clinic, 1230 East Main Street, P.O. Box 8674, Mankato, MN, 56002-8674; phone: 507-389-8654; fax: 507-625-4353; email: ddavito@mankato-clinic.com
www.mankato-clinic.com
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MINNESOTA PHYSICIAN JUNE 2011
Confidential inquiries can be made by calling Jodi Johnson at 651-379-1714. You may also send your CV and cover letter to: Nystrom & Associates, Ltd. Attn: Human Resources 1900 Silver Lake Road Suite 110, New Brighton, MN 55112 Or email to: humanresources@nystromcounseling.com
Visit our website at: www.nystromcounseling.com
Come to the Alexandria Lakes Area...
Opportunities available in the following specialty:
• Dermatology • Emergency Medicine • Family Medicine • Internal Medicine • Pediatrics Broadway Medical Center is a rapidly growing, independent, physician-owned multi-specialty group practice with over 35 caregivers in 10 different medical specialties. We are located in Alexandria, MN; a beautiful and growing community with tremendous recreational opportunities. Welcome! Contact Daniel J. Jones, MHA at Broadway Medical Center 1527 Broadway Street, Alexandria, MN 56308 (320) 762-6841 or e-mail djjones@broadwaymedicalcenter.com
1527 Broadway Street, Alexandria, MN 56308
To learn more about our practice, please visit our website at www.broadwaymedicalcenter.com
Olmsted Medical Center, a 150-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.
Family Medicine Rochester Northwest Clinic Rochester Southeast Clinic St.Charles Clinic Internal Medicine Southeast Clinic Occupational Medicine Southeast Clinic Dermatology Southeast Clinic
Send CV to: Olmsted Medical Center Administration/Clinician Recruitment 1650 4th Street SE Rochester, MN 55904
Olmsted Medical Center offers a competitive salary and comprehensive benefit package.
email: egarcia@olmmed.org Phone: 507.529.6610 Fax: 507.529.6622 EOE
www.olmstedmedicalcenter.org
St. Cloud VA Medical Center is accepting applications for the following full or part-time positions:
• Internal Medicine
• Geriatrician
(Nursing Home— St. Cloud, Brainerd)
(Nursing Home—St. Cloud)
• Hematology/Oncology
• Family Practice
(St. Cloud)
(St. Cloud)
• Neurology (St. Cloud)
• Psychiatrist (St. Cloud) • ENT
(St. Cloud)
• Dermatology (St. Cloud) • Disability Examiner (IM or FP) (St. Cloud)
US Citizenship required or candidates must have proper authorization to work in the US. J-1 candidates are now being accepted for the Hematology/Oncology positions. Physician applicants should be BC/BE. Applicant(s) selected for a position may be eligible for an award up to the maximum limitation under the provision of the Education Debt Reduction Program. Possible relocation bonus. EEO Employer.
Excellent benefit package including: Favorable lifestyle Competitive salary 26 days vacation 13 days sick leave CME days Liability insurance Interested applicants can mail or email your CV to VAMC Sharon Schmitz (Sharon.schmitz@va.gov) 4801 Veterans Drive, St. Cloud, MN 56303 Or fax: 320-255-6436 or Telephone: 320-252-1670, extension 6618
JUNE 2011
MINNESOTA PHYSICIAN
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Ankle from page 38 too tightly. Orthotics such as pads in the front of the shoe can relieve pressure. While the pain can be significant—and often mimics that of a stress fracture—rest, not surgery, is needed. Regularly stretching the calf muscles and strengthening the extensor muscles also help reduce the likelihood of re-injury. Fractures
About 15 percent of all ankle injuries are fractures. As part of the exam, clinicians should ask patients about any previous ankle trauma, whether an audible sound like a “pop” was heard when the injury occurred, and weight-bearing ability. According to the Ottawa ankle rules, the inability to bear weight immediately after an injury or at the time of an x-ray, along with specific locations of bone tenderness, indicate the need for radiographic examination because of increased risk of a clinically significant fracture. Providing patients comfort following a fracture requires
Future developments likely will include new imaging methods, improved rehabilitation techniques, the role of nutrition in inflammation and healing, and musculoskeletal tissue engineering. pain management and immobilization of the fracture. Patients sometimes are referred to an orthopedist in cases of displaced ankle fractures, possible unstable injuries, and bimalleolar and trimalleolar fractures. Achilles tendonitis
Most patients with Achilles tendonitis have inflamed the tendon in the back of the ankle by overpronation and lack of flexibility. Exercise-related tendonitis pain is most intense during “pushing off” or jumping. Running is a common precursor to Achilles tendonitis, along with sports that require jumping, such as basketball. Achilles tendonitis generally does not require surgery. Resting the tendon promotes healing and reduces inflammation. Immobilization
Growing multi-specialty group practice in Northern Minnesota is looking for a BC/BE Family Practice Physician, Internal Medicine Physician, Emergency Room Physician, OB/GYN Physician, Urologist as well as an Orthopaedic Surgeon. Join an existing group practice and take over existing practices from departing physicians. Grand Itasca Clinic & Hospital in Grand Rapids, Minnesota has recently opened a new state of the art clinic & hospital. Excellent salary guarantee with outstanding income potential, full benefits and sign-on bonus. Community located in the beautiful northern Minnesota lakes area.
Contact: Gail Anderson (218) 999-1447 gail.anderson@granditasca.org. 40
MINNESOTA PHYSICIAN JUNE 2011
and crutches may be needed. Besides ice and NSAIDs, a new anti-inflammatory topical gel may be effective. Using a heel wedge or lift in shoes reduces impact on the tendon. Most injections to treat Achilles tendon problems should be avoided. PRP (platelet-rich plasma) injections have not been shown to be useful, and cortisone can contribute to tendon rupture. Preventing injuries involves maintaining flexibility in the ankle joint, including regularly stretching the Achilles tendon, and orthotics to support the foot and correct abnormalities such as overpronation. Chronic ankle instability
Patients diagnosed with chronic ankle instability feel like the lateral side of their ankle often
“gives way” when walking, exercising, or simply standing. Weakened ligaments cause the instability, which can develop after multiple ankle sprains, especially following a sprain that did not heal sufficiently. X-rays, CT scans, or magnetic resonance imaging scans may be used in diagnosis. The patient’s activity level also guides treatment. Nonsurgical options range from use of NSAIDs to manage pain and inflammation to physical therapy and use of an ankle brace for support. Surgery to repair or reconstruct damaged ligaments and, in some cases, to perform other soft tissue or bone procedures, is needed for more serious injuries or in cases not responding to other regimens. Arthritis in the ankle
While not an ankle injury, arthritis in the ankle can result from a previous ankle injury. Patients with “ankle arthritis” have worn out the tibiotalar joint, typically due to: 1) cartilage damage from a fracture; 2) injury-related ANKLE to page 42
Mercy Medical Center-North Iowa is at the center of a 9 hospital/ 44 clinic premier rural health care delivery network. Enhance your personal and professional life with low cost of living, competitive compensation and benefits, and a financially stable and growing health system. Practice where your skills are appreciated. Live where you and yours will flourish as you become rooted in a lifestyle second to none!
- Family Medicine (OB) - Pediatrics - Neurology - Occupational Medicine - Family Medicine - Ophthalmology - Neurosurgery
- Hospitalist (IM) - Psychiatry - Urology - Chief Medical Informatics Officer - Family Medicine Faculty - Emergency Medicine
Contact Denise Siemers, Physican Recruitment Mercy Medical Center – North Iowa Phone: (888) 877-5551 or (641) 428-5551 CV to: PRACTICE@mercyhealth.com
- Rheumatology - Hematology/ Oncology - Bariatric Surgery - Vascular Surgery - Palliative Medicine Fellowship Director - Hospice Director
Practice Well. Live Well.
JOIN/BUY IN the Leading Minneapolis Anti-Aging and Preventive Medicine Clinic
Lake Region Healthcare is located in a magnificent, rural, and family-friendly setting in Minnesota lakes country where we aim to be the state’s preeminent regional health care partner.
Anti-Aging Medicine is the fastest growing field of medicine today.
Our award winning patient care and uncommon medical specialties set us apart from other regional health care groups. Lake Region’s physicians and their families also enjoy an unmatched quality of professional and personal life.
You will be coached by a leading Anti-Aging Specialist in the country in a truly satisfying practice. • Improve vigor, vitality, and • Good earning potential looks of your patients • Expansion opportunities • Delay diseases of aging • NO evenings and weekends
Current opportunities including competitive salary and benefit packages available for BE/BC physicians are: • Internal Medicine • Internal Medicine • Pediatrics • Pediatrics
• Family Medicine • Urology • Family Medicine • General Surgery • Psychiatrist • General Surgery
Innovative Directions in Health
Physicians with background in internal medicine, family medicine and emergency medicine preferred.
For more information contact
Edina, MN
Barb Miller, Physician Recruiter bjmiller@lrhc.org • (218) 736-8227
Khalid Mahmud, MD, FACP
712 Cascade St. S. Fergus Falls, MN 736-8000 | (800) 439-6424
To learn more about our practice, visit www.idinhealth.com
Lake Region Healthcare is an Equal Opportunity Employer. EOE
Contact Lisa Rhodes at (952) 922-2345 or lisa@idinhealth.com
Urgent Care Minneapolis/St. Paul
The perfect match of career and lifestyle. Affiliated Community Medical Centers is a physician owned multi-specialty 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: • Family Medicine • General Surgery • Geriatrician/ Outpatient Internal Medicine • Hospitalist • Infectious Disease
• Internal Medicine • Oncology • Orthopedic Surgery • Pain Management • Psychiatry
We have part-time and on-call positions available at a variety of Twin Cities’ metro area HealthPartners Clinics. Evening and weekend shifts are currently available. We are seeking BC/BE full-range family medicine and internal medicine-pediatric (Med-Peds) physicians. We offer a competitive salary and paid malpractice.
• Pediatrics • Pulmonary/ Critical Care • Radiation Oncology • Rheumatology
For consideration, apply online at healthpartners.jobs and follow the Search Physician Careers link to view our Urgent Care opportunities. For more information, please contact diane.m.collins@healthpartners.com or call Diane at: 952-883-5453; toll-free: 1-800-472-4695 x3. EOE
For additional information, please contact: Kari Bredberg, Physician Recruitment karib@acmc.com, 320-231-6366 Julayne Mayer, Physician Recruitment mayerj@acmc.com, 320-231-5052 www.acmc.com
healthpartners.com ©
JUNE 2011
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Ankle from page 40 osteonecrosis; 3) joint inflammation and cartilage damage due to rheumatoid disease; 4) infection in a joint that damaged cartilage cells; 5) genetic tendency; and/or 6) being overweight. Most patients find symptom relief with changes in footwear, such as cushioned inserts or “rockerbottom” soles, and by limiting high-impact activities. Besides NSAIDs for inflammation and pain, cortisone injections are used during flare-ups, along with a brace to hold the ankle joint in position. Some patients need to have bone spurs shaved in order to achieve proper joint motion, or need ankle fusion surgery to reduce pain. Advances in ankle replacement surgery are enabling better range of motion and functioning. Heel fractures
Sixty percent of tarsal fractures involve the calcaneus, according to the AAOS. Heel bone fractures are often severe and disabling. Beyond confirming the fracture by x-ray, computed
tomography scans show severity and enable the most effective treatment plan. An immobilization device is used if the broken bones have not been displaced. Otherwise, surgery restores the normal anatomy. The AAOS notes that research for improving outcomes has focused on three areas: • Smaller incisions used for fixing the fracture • Defining which treatment method works best for which type of fracture and for which “type” of patient—for example, smokers or people with diabetes • Inventing better plates and screws Treatment advances
Advances are being made in diagnosing and treating musculoskeletal injuries, including those of the ankle and foot. According to the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), they include arthroscopy, tissue engineering, and targeted pain relief.
Arthroscopy. The biggest advance is using arthroscopy to view joint problems without major surgery. Tiny incisions mean less trauma, swelling, and scar tissue than with conventional surgery, as well as decreased hospitalization and rehabilitation. In addition, because injuries often are addressed earlier, success is more likely. Tissue engineering. Injured joint cartilage does not heal on its own as other tissues do. Techniques such as transplanting one's own healthy cartilage or cells to improve healing are used today for small cartilage defects. Questions remain about the usefulness and cost of this treatment. Targeted pain relief. New pain-killing, medicated patches and gels can be applied directly to an injury site rather than taken systemically, thereby limiting some of the potential side effects. Treatments on the horizon
• Technical advances and new imaging methods for improved diagnosis and treatment • Improved rehabilitation techniques that may reduce the need for surgery • Treatment improvements based on the role of nutrition in inflammation and healing • Musculoskeletal tissue engineering Most of the ankle injuries that we see in our 24-hour urgent care service are minor and heal relatively quickly with proper instructions and treatments initiated promptly after the injury occurs. It’s good to know, however, that advances in the care of ankle and foot injuries are being made in a wide area of diagnostic and therapeutic options, enabling people to resume healthy and active lifestyles more quickly and completely. Sumner McAllister, MD, practices family medicine at Apple Valley Medical Clinic within the Apple Valley Medical Center.
According to NIAMS, future developments likely will include:
continuing medical education Fundamental Critical Care Support
July 14 - 15 and October 13 - 14, 2011
29th Annual Strategies in Primary Care Medicine • Basic Life Support (BLS) for Health Care Providers – Recertification • Hospital Medicine, 2011 Update
September 22 - 23, 2011 September 23, 2011 September 23, 2011
Pediatric Trauma Summit
September 22 - 23, 2011
Pediatric Conference • Best Practices – Managing the Pediatric Patient in an Urgent Care Setting • Pediatric Update Conference – Beyond the Basics 11th Annual Women’s Health Conference
November 4, 2011
Emergency Medicine and Trauma Update: Beyond the Golden Hour
November 17, 2011
Otolaryngology for Primary Care
November 18, 2011
33rd Annual Cardiovascular Conference
education that measurably improves patient care 42
October 28, 2011 October 29, 2011
MINNESOTA PHYSICIAN JUNE 2011
December 1- 2, 2011
healthpartnersIME.com
You wouldnâ&#x20AC;&#x2122;t give a 4-year-old a drink, so why would you give one to an unborn child? As a physician, itâ&#x20AC;&#x2122;s your responsibility to let her know: the U.S. Surgeon General Advisory says no amount of alcohol is safe during pregnancy. Share 049: Zero Alcohol For Nine Months.
www.mofas.org