Health care facilities can be stressful places for patients and visitors, with depressing waiting rooms, rows of uncomfortable seating, a blaring television. But designers of some medical spaces are remedying the situation.
A more holistic approach includes mood-elevating colors and artwork. Chairs are angled to look out the window. Screens offer calming nature scenes instead of newsfeeds. There’s softer overhead lighting and skylights. Sometimes, diffusers even waft a gentle breeze of lavender or citrus to mask the harsh scents of disinfectants and medicines.
Sheila Semrou, a Milwaukee-based design consultant who has worked on numerous health-care facilities, says she takes inspiration from local scenery and geography. Think big windows, natural light and a palette that reflects outside vistas.
“The results can be supportive spaces that nurture occupants and provide comfort,” she says.
New research is showing that a lot of clinical design norms are hard on patients, she says. Bright, polished floors can be slippery, and create glare. Bland color schemes aren’t so much soothing as uninspiring.
“Studies suggest that some of the best environments for health and healing incorporate a variety of hues, use both warm and cool tones, and vary color saturation,” Semrou says.
At the Diane L. Max Health Center in New York City, a project by Stephen Yablon Architecture, upbeat primary and neon colors were used on midcentury-style seating, facades and to define different areas of the building.
On the other hand, in the reception area of Memorial Sloan Kettering in West Harrison, New York, blonde terrazzo floors, rift white oak and chic, light blue chairs clad in walnut veneer create a serene space, designed by EwingCole.
In colder climes, a fireplace can add a welcoming feel at little cost, says Carolyn BaRoss, who leads a health-care interior design division at the New York firm Perkins and Will.
“A number of our projects in Canada and the northwestern U.S. have included fireplaces as part of the waiting areas and other lounges,” she says. “We try to specify ones that look the most realistic and surround them with interesting materials. We’ve used both electric and gas fireplaces. They provide a source of warmth, but are fitted with a protective enclosure for safety.”
BaRoss says an Orlando, Florida, project, Nemours Children’s Hospital, has a “hospital in a garden” theme, with nature elements, daylight and views woven into the design. There are small “picnic blanket” designs in the flooring pattern, and child-size play areas, as well as “ceiling elements like the large flower in the dining area.”
Treatment areas are also benefiting from this kind of patient-focused design. The Florida Hospital for Children in Orlando and the Women and Children’s Hospital in Adelaide, Australia, are among facilities offering the “Philips’ Ambient Experience” in MRI suites. Patients select a lighting color, as well as audiovisual projections like nature scenes, to help ease anxiety during the procedures.
At Mercy St. John’s Hospital in St. Louis, an enormous vibrant butterfly greets visitors in the lobby, while patient floors are decorated with laser-cut images of animals.
BaRoss says new LED technology allows for more dimmable, flattering lighting, which can also be used to help patients find their way in a new facility.
At the Colorado Center for Reproductive Medicine in New York City, designed by Perkins and Will, chairs face out onto the cityscape. Look out the window, and you’ll also see Robert Indiana’s large “Hope” sculpture on the street below.
“The waiting room is typically where a patient will spend the most time. With that in mind, we took care to design an environment that’s low-stress and soothing,” says Dr. Brian Levine, the practice’s director.
“We took advantage of the views by placing our waiting room in the brightest and most visually stimulating aspect of our floor plan. We chose light-colored wall coverings, flooring, and furniture to help reflect and carry the light throughout the room, so no patient would ever feel like they’re in a ‘dark corner,’” he says.
Melissa Thompson, a health-care industry strategist from Westport, Connecticut, developed breast cancer shortly after giving birth to her daughter in 2015, and began a long treatment journey. The experience got her thinking about how important physical environment was to her comfort and, she believes, even her recovery.
She didn’t stay long at the first hospital she went to: “It smelled bad — like an old cafeteria full of chemicals.”
But Greenwich Hospital in Connecticut and Memorial Sloan Kettering in New York City were a different story. Rooms were oases of natural woods and light. Both hospitals had lounge areas where patients could relax outside of their rooms in a warm, comfortable atmosphere.
“I was noticeably happier, and discharged sooner,” she says.
/wp-content/uploads/2020/08/florida-medical-space-logo.png00admin/wp-content/uploads/2020/08/florida-medical-space-logo.pngadmin2017-03-28 03:26:482017-03-28 03:26:48Designers Take A Holistic Approach To Health Care Spaces
Palm Beach Gardens Medical Center, or at least the real estate where the hospital operates, has a new owner.
Tenet Healthcare paid landlord HCP Inc. $43.4 million for the 282,000-square-foot facility on Burns Road, according to property records. HCP is a California-based real estate investment trust that specializes in medical facilities.
The companies also recorded a lease termination. Palm Beach Gardens Medical Center is in the midst of a $16 million renovation.
The Palm Beach County Property Appraiser records no previous sale price for the hospital, but HCP says in its latest annual report that it paid $24.9 million for the facility in 2011.
Dallas-based Tenet Healthcare operates 10 hospitals in Florida, and the 199-bed Palm Beach Gardens Medical Center was the only one it leased rather than owned, according to the company’s latest annual report.
/wp-content/uploads/2020/08/florida-medical-space-logo.png00admin/wp-content/uploads/2020/08/florida-medical-space-logo.pngadmin2017-03-23 03:11:082017-03-23 03:11:08Tenet Buys Palm Beach Gardens Medical Center
Health care REITs face some challenges, which we expect to result in slower, albeit still positive, earnings growth in 2017. These challenges include slowing fundamentals for the senior housing sector and rising capital costs.
Over the past several years, health care REITs have expanded their senior housing portfolios substantially. Health care REITs are attracted by the sector’s focus on private pay sources of revenue and good demand from the growing population of seniors, which is living longer and wants residential care that offers assistance with daily activities and light medical needs. However, new supply of senior housing is rising and wage expense pressures are building in many U.S. markets. These trends are credit negative for health care REITs, and as a result, we expect more modest earnings growth for the REITs in 2017, particularly as many REITs have assumed more operating exposure via the use of taxable REIT subsidiaries. These subsidiaries allow the REITs to directly realize the properties’ net income after paying a third-party management fee. Health care REITs also invest via triple-net-lease structures, which limit the risk to the operators’ ability to keep making rent payments.
The operations of the taxable REIT subsidiaries have been a strong source of profit growth over the past few years for health care REITs. This profit growth has already begun to slow, however, and we expect it will continue to decelerate as more supply comes on line and as higher labor costs persist in 2017.
The extent of the downside for REITs will depend on the strength of their operating partners, as well as supply-demand characteristics within their sub-markets. For their triple-net-lease portfolios, tenant diversification and strong rent coverage ratios (1.2x or greater) are other key mitigating factors.
Another key challenge is the increasing cost of capital. Health care REITs rely on cost-effective access to debt and equity capital to finance acquisitions that drive their earnings growth. They also rely on external capital to refinance ongoing debt maturities, given their limited structural ability to retain cash flow. However, their debt costs are rising and their stock prices remain volatile owing to the prospect of rising interest rates, a situation that is resulting in compressed spreads earned on new investments and higher refinancing costs.
We expect rising capital costs to remain a credit challenge for health care REITs in 2017. The 10-year US Treasury yield rose to 2.48 percent as of Feb. 1, 2017, up from a low of 1.37 percent as of July 5, 2016. Moody’s Analytics expects the 10-year to rise to 2.9 percent by year-end 2017, and to 3.7 percent by year-end 2018.
Longer term, we expect health care REITs to reap some benefits from rising rates. Higher borrowing costs will affect all potential real estate buyers, both private and public, prompting asset prices to come down from the current, historically high levels. However, it will take time for prices to adjust to the changing rate environment, and we expect the earnings growth of health care REITs to slow accordingly this year. This modest growth outlook could present credit challenges if it were to incent REITs to use more leverage or riskier transaction structures to boost their profitability.
/wp-content/uploads/2020/08/florida-medical-space-logo.png00admin/wp-content/uploads/2020/08/florida-medical-space-logo.pngadmin2017-03-19 23:39:372017-03-19 23:39:37Health Care REITs: Developments To Watch In 2017
Real estate investment trust Duke Realty Corp (DRE.N) is exploring the sale of its medical office buildings that could be worth as much as $3 billion, as it seeks to focus on its warehouse portfolio, people familiar with the matter said.
The move represents the latest strategy shift for the Indianapolis-based company, two years after it decided to shed its suburban office properties to shield itself from volatility in the wider U.S. commercial real estate market.
Duke Realty is working with investment bank Morgan Stanley on the sale of its medical office portfolio, which has attracted the interest of healthcare-focused REITs, the sources said this week. The sale process is ongoing and there is no certainty it will result in a deal, the people added.
The sources asked not to be identified because the matter is confidential. Duke Realty and Morgan Stanley did not immediately respond to requests for comment.
Duke Realty shares jumped as much as 1.3 percent on the news to $26.03, giving the company a market capitalization of more than $9.3 billion.
Duke Realty owned a portfolio of 561 commercial properties in 21 major U.S. metropolitan areas encompassing 139.6 million net rentable square feet as of the end of December, according to its latest annual report. Out of those, 455 were bulk distribution industrial properties and 86 were medical office buildings.
The divestiture would leave Duke Realty’s portfolio comprised almost solely of industrial properties. These have been among the real estate sector’s strongest performers because of the advent of internet shopping, which has buoyed demand for warehouse space to store and process goods for shipment.
“The REIT’s well-located portfolio of industrial assets should continue to benefit from accelerating demand for high-quality logistics product and measured supply growth,” Moody’s Investors Service Inc analyst Alice Chung wrote in a note in November.
While Duke Realty’s medical office properties have proved resilient in economic downturns, their fortunes are tied to those of hospitals they share a campus with. Many hospitals are expected to take a hit if the Affordable Care Act is repealed, because fewer patients are expected to be covered by the alternative.
As well, the growth rate of rents in Duke’s medical office building portfolio has lagged that of its industrial properties. Real estate investors tend to reward REITs that focus on a single type of real estate, and buy or develop similar quality properties.
/wp-content/uploads/2020/08/florida-medical-space-logo.png00admin/wp-content/uploads/2020/08/florida-medical-space-logo.pngadmin2017-03-15 21:57:162017-03-15 21:57:16Duke Realty Mulls Sale Of Medical Office Buildings
Last September, The Hospitals of Providence, a leading healthcare provider in El Paso, Texas, broke ground for a new medical campus on 10 acres in suburban Horizon City, 20 miles east of El Paso. There they will build a 40,000-sf “microhospital” to house an emergency department, a laboratory, imaging services, and 10 to 12 inpatient beds. The campus will also have 50,000 sf of office space for physicians and staff.
Microhospitals are acute care facilities that are smaller than the typical acute care hospital. They leave complex surgeries to the big guys, but are larger and provide more comprehensive services than the typical urgent care or outpatient center. They range in size from 10,000 sf to 60,000 sf.
Microhospitals offer the full services of a hospital emergency department and have labs that provide rapid clinical diagnostics and x-ray, CT, and ultrasound imaging. According to healthcare consultant Advisory Board, microhospitals can meet up to 90% of the healthcare needs of the communities they serve. And they never close.
Like urgi-centers and outpatient clinics, microhospitals generally treat patients with low-acuity medical problems. Unlike urgent care and outpatient facilities, they have inpatient beds (typically anywhere from eight to 15) and can support overnight observation of patients who require low-acuity hospital services.
The Horizon City microhospital, which will employ 75 clinical and nonclinical staff when it opens in September, will fill a gap in the availability of hospital-level services for Horizon City (2013 population: 18,997), whose area population has ballooned 180% over the past 16 years. “Initially, we had planned to go with a freestanding ED with imaging functions, but we took a step back and concluded that wouldn’t be enough,” says Sally Hurt-Deitch, Hospitals of Providence’s Market CEO. Hospitals of Providence has plans to open at least two more microhospital facilities.
Microhospitals are the latest twist in “population health,” as healthcare systems search for ways to bring quality care to demographic markets that can’t support full-size hospitals and offer such care closer to where people live and work.
“The days of us building 200,000-sf hospitals are over,” proclaims Isaac Palmer, CEO of Christus Health. Next fall, Christus will open the first microhospital in Louisiana, a 10,000-sf facility in Shreveport-Bossier with six short-stay inpatient beds. “It’s kind of a souped-up doctor’s office,” says Palmer. “We’re moving toward microhospitals to enhance our integrated delivery network,” says Laura Hennum, Chief Strategy Officer at Dignity Health. “It’s all about population health and one-stop shopping for consumers.”
At the close of 2016, there were at least 50 microhospitals operating in the U.S., according to Environments for Health (E4H) Architecture, which has designed a dozen of them. Micros are particularly popular in parts of the Midwest and certain western states, notably Arizona, Colorado, Nevada, and Texas. Most of the microhospitals in operation or under construction are located in states that don’t have certificate of need programs aimed at controlling overbuilding of healthcare facilities.
“This is a new concept,” says Chris DiGiusto, Corporate Vice President of Ambulatory Services with Franciscan Alliance, Indianapolis. The 14-hospital system will break ground on a 20,000-sf, $12 million microhospital with 12 emergency exam rooms and eight inpatient beds next month. “It’s like a tiny house: the essentials and nothing else,” he says.
DiGiusto admits that competition entered into Franciscan’s decision to plug a micro into the larger $50 million medical complex it’s building. St. Vincent Health, a 20-hospital system, has announced plans to build eight microhospitals in central Indiana, each with eight beds. DiGiusto says that St. Vincent’s first micro “will be right in Franciscan’s [patient] catchment area.”
CHEAPER AND QUICKER TO BUILD
Hospital admissions have declined in recent years, as patients have chosen to patronize clinics in pharmacies, urgent care centers, freestanding outpatient facilities, ambulatory procedure operations, and independent emergency care centers. Microhospitals have become service bridges between EDs and hospitals, especially in markets that lack convenient patient access to large hospitals.
“Some clients look at micros as an alternative to investing huge amounts of money in larger healthcare facilities,” says Catherine Corbin, Principal and Chicago Health Practice Leader for CannonDesign, which has prepared a tactical report on “Microhospitals: Inpatient Services with Outpatient Convenience.” Corbin says that health systems also see micros as a way of “planting their flag in new communities” and expanding their services outside of urban areas.
Microhospitals have been around for at least a decade, but they’re starting to proliferate. They’re cheaper to build than giant regional hospitals, averaging between $7 million and $35 million in construction costs, with much shorter build times—about 12 to 14 months, according to AEC industry sources.
They can also bill patients at the same rate as acute care hospitals. Their reimbursement from private insurers and Medicare and Medicaid is generally higher than for freestanding EDs or urgent care, outpatient, and freestanding surgical centers.
“For a freestanding ED to get maximum reimbursement, it either needs to be tethered to the mother ship or it has to build its own hospital,” says Rod Booze, AIA, ACHA, NCARB, Principal, E4H Architecture.
GOING OUTSIDE THE SYSTEM
So far, most microhospitals have been developed, constructed, and operated by third-party management companies through joint-venture agreements with health systems. They can be pretty secretive about their business models and facility designs.
Embree Asset Group, Georgetown, Texas—whose partners include Indiana’s St. Vincent Health and St. Luke’s Health System, based in Kansas City, Mo.—would not identify AEC firms it has worked with. Texas-based Adeptus Health, which reportedly operates a few micros, wasn’t available for comment.
The clear leader among microhospital management companies is Emerus Holdings, Woodlands, Texas, which was launched in 2006 by a group of emergency-care physicians. At the end of 2016 Emerus was operating 22 micros with more than 1,500 employees for various healthcare systems across the country. Emerus intends to triple its complement of facilities and systems partners and quadruple the number of states in which it operates by 2020.
Emerus’s prototype delivery model can be adapted to meet the needs of specific communities and patient demographic niches, says Dudley Carpenter, the company’s Senior Vice President of Real Estate.
Emerus prefers building from the ground up, typically on three acres; the company finds “little value” in retrofitting existing buildings, he says. The nurses’ stations have been designed to optimize sightlines and accessibility. CT and x-ray rooms emphasize patient comfort. Some of its micros have staffed surgical suites with anesthesia, post-operative care, and pain control capability.
“The bottom line comes from the square footage,” says Carpenter. “We are a hospital but it’s not a footprint with 100 or more beds. We bring that down to about 20,000 sf.” That also lessens the burden on local communities’ power and water resources, he notes.
The health systems with which Emerus partners are the “established brands” that confer legitimacy to the micros, says Carpenter. Sources at those systems respect Emerus’s track record. “Emerus is an organization that has executed microhospitals successfully,” says Hospitals of Providence’s Hurt-Deitch. “They fit our model.” She explains that micros can support the larger system without requiring the same manpower as a full-scale hospital. In some cases they can actually share staff and professionals with the acute care hospital.
Micros can also be more patient-friendly than other delivery formats. Dignity Health’s Hennum notes that the average admission-to-discharge time for all healthcare facilities in Nevada is 154 minutes; at Emerus-operated facilities, it’s less than half that: 74 minutes.
Franciscan is among the holdouts that have chosen to develop and operate microhospitals on their own. “We couldn’t get the math to work out right” by using a third-party management partner, says DiGiusto. “The margins were too thin.”
DiGiusto also wasn’t overly impressed with other micros he’s looked at. “They’re basically urgent cares open 24 hours a day with CT scanners. We didn’t think they’d meet our quality standards.”
MICROHOSPITAL OPPORTUNITIES OPENING UP FOR CONTRACTORS
Only a few AEC firms have engaged in microhospital projects. The Building Team on Franciscan’s complex, for example, includes Arc Design (architect and designer), KJWW (MEP), Crossroads Engineering (CE), Mader Design (landscape), and Tonn & Blank (GC).
Emerus has had a long-standing relationship with Houston-based architecture firm PhiloWilke Partnership. The first micro that PhiloWilke designed for Emerus was a retrofit and expansion of an 8,000-sf ED in a strip mall in Sugar Land, Texas. The facility had two inpatient rooms, eight exam rooms, a dietary department, and some imaging capability, all squeezed into 13,000 sf. That was a test run for Emerus’s first official microhospital, which opened in Tomball, Texas, in 2006.
After taking a timeout to refine its prototype and business model, Emerus built five micros in San Antonio in 2010, one of which was a converted 26,000-sf shoe store. Since then, PhiloWilke has developed several microhospital prototypes for Emerus, says Kevin TenBrook, AIA, LEED AP, a Partner at the design firm.
Emerus’s first-generation micros had a footprint of about 20,000 sf with a second floor (and sometimes a third) for office space. There was also a single-story model for tight plots. The second generation is three floors in a 13,000-sf footprint.
TenBrook says his firm’s microhospital designs for Emerus “have as much space for patients as full-size hospitals.” Over the years, PhiloWilke has been able to get construction costs down to 60% of the original prototype. It is now exploring what kind of micro could be built on a half acre.
PhiloWilke’s designs, says TenBrook, fall within the “spirit” of guidelines for hospitals put forth by the Facilities Guidelines Institute, the independent nonprofit that provides guidelines for the design of medical facilities. FGI does not have specific requirements for microhospitals and has yet to address differences between microhospitals and critical access hospitals, says FGI spokesperson Douglas Erickson.
While PhiloWilke has captured the lion’s share of Emerus’s design work, Emerus and its healthcare partners are drawing from a wide pool of contractors for microhospital construction. In Dallas, Baylor Health Care System favors Medco Construction. In San Antonio, Gilbane, Vaughn Construction, and F.A. Nunnelly have built or are building micros for other health systems. S.R. Construction and Martin Harris have been used in Las Vegas, Kiewit Building Group in Colorado, and Anderson Construction in Idaho.
ARE MICROS A SUSTAINABLE TREND, OR JUST ANOTHER FLASH IN THE PAN?
TenBrook is convinced that Emerus has created a viable product that “makes sense from an investment point of view.” He points to Baptist Emergency Hospital’s recently opened 38,500-sf micro at Zarzamora, in South San Antonio—once a “healthcare desert,” he claims—that has been handling twice the average patient load than was originally projected. (Depending on the market, microhospitals expect to see anywhere from 30 to 100 patients a day.)
Dignity Health plans to include medical office spaces and wellness centers in its micros and is considering leasing space for physical therapy and ambulatory surgery centers, says Hennum. Dignity will measure three variables—market demand, patient experience, and clinical outcomes—to determine whether its microhospitals are working, to decide if it will build more of them. Hennum says Dignity is looking into opening micros in California.
But healthcare construction trends come and go. It wasn’t too long ago that experts thought there were no limits to the growth of medical office buildings; in many markets, MOBs now seem passé, as patients choose other types of care facilities that fit their medical needs and tight wallets better.
Then there’s the cautionary tale of Adeptus Health, the nation’s largest ED operator, which lost $11.7 million in Q3/2016 and saw its stock price plummet by 88.4% from May 16 to $7.43 on December 22. Is Adeptus’s precipitous decline a signal that its business model, which relies heavily on non-hospital-affiliated emergency departments and on charging patients “facility fees” to cover its overhead, might not be sustainable?
(Emerus Senior Vice President Jason Jisovicz says his company has avoided Adeptus’s financial problems by using in-network services.)
There’s also no consensus about how quickly or broadly microhospitals might spread. Franciscan’s board has given DiGiusto approval to explore replicating the micro model at other Franciscan facilities: “We need to take some pressure off of our hospitals, which are regularly out of beds,” he says. But he doesn’t foresee micros having anywhere near the same growth trajectory of, say, urgent care centers. “You need special circumstances,” he says, especially regarding location: Micros only work in communities that don’t have ready access to a large acute care hospital.
CannonDesign’s Corbin says interest in microhospitals could last another five years, but she also expects states to tighten their reins on what kinds of healthcare facilities they allow. She says some investors already view the investment cycle of micros as being closer to medical office buildings (10–15 years) than full-size acute care hospitals (50 years).
PhiloWilke’s TenBrook says the only thing keeping microhospitals from becoming more mainstream is state regulations that are, in his view, “out of sync with the idea of a small hospital.” To meet one state’s code, he says, his firm had to produce a design template showing four janitors’ closets in every micro, when one or two would have been more than sufficient.
E4H’s Booze says the precariousness of the Affordable Care Act, which spurred healthcare growth over the past five years, makes predicting hazardous. He says one client in the Northeast that he would not name views microhospitals as “a growth instrument in a nongrowth market.”
Booze believes that as long as healthcare providers and private developers see micros as a real estate infill play, some day there could be up to 250 microhospitals dotting America’s countryside.
