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Private Equity Expanding Pursuits in Health Care Investment

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Chris Zuccarini, Managing Director, National Health Care Practice, Risk Strategies Company

The trend of private equity (PE) firms seeking high returns in health care has been in full bloom for more than a decade. But whereas previously PE was focused on a top-down approach of buying hospitals and health systems, that focus has begun to shift toward less-costly, smaller specialty groups and physician practices.

Bain & Company’s 2021 Global Healthcare Private Equity and M&A Report found that investors are pursuing new “buy-and-build” strategies in less-penetrated segments of the provider sector. The report notes that there is increased focus among PE firms on areas that are promoting the shift toward home-based and outpatient care, along with “risk-bearing targets” like Medicare Advantage providers operating under capitation models and behavioral health providers.

Mission Alignment is Essential

For health care entities considering an investment from a private equity firm, the risk/reward calculus is complicated by recent downturns in patient volume and revenues due to COVID-19. The pandemic exposed the weaknesses that small providers face in a fee-for-service (FFS) environment and amplified the need for health care companies to maintain sufficient capital resources on hand to remain competitive and viable

The short-term financial windfall that may come from an acquisition must be weighed against the long-term implications, especially for physician practices who need to consider whether they are going to be part of an eventual sale. PE firms have a term of exit, typically within five to seven years, to meet shareholder obligations, so it is fair to raise a concern about what happens when that time is up.

Perhaps most importantly, compatibility relies on cultural alignment between PE firms and health care organizations. The economic model must support the care mission. Ensuring that the missions of the acquiring and acquired organizations are transparent and well aligned is critical for successful outcomes.

Improvements in Efficiency and Accountability

Partnerships between PE firms and medical groups have proven especially advantageous for easing the administrative burden for smaller providers. PE provides practices with a backstop to improve cash cycles and back-office processes, such as management reporting and compliance work.

PE investment has also allowed post-acute companies to grow and test new business models, delivering greater access to in-home care and telehealth. Technology is breaking down the traditional brick–and- mortar localized care delivery system, expanding access and lowering costs. PE brings the capital, and the know-how, to build these assets at scale.

In addition, the involvement of a PE firm creates visibility into the performance of a health care business, holding internal teams accountable for efficiencies to satisfy shareholders while delivering exemplary patient care. In August 2020, a JAMA study found hospitals acquired by PE firms experienced increases in net income as well as improvement in quality metrics.

Thinking Long Term

The health care industry is in a mature stage of PE involvement in core hospital service. With increased segmentation across the industry, the trend is growing and shifting. A JAMA study released in February 2020 found that more than 350 physician practices were acquired by PE firms between 2013 and 2016. The study concludes that PE firms see ample business opportunities in the physician practice space, expecting annual returns greater than 20%, though there remain “unknown implications for care delivery and patient outcomes” in the future.

Provider leaders should consider what they need long-term out of a PE transaction, secure commitments to quality and ensure that the new management will continue to invest as the industry moves away from FFS and expands into new business models.

Practices also need to consider the legal and compliance complexities that can arise out of the new administrative structures resulting from a PE investment. Risk Strategies Health Care Practice experts have extensive experience evaluating and advising on these partnerships and stand ready to help you achieve the best possible outcomes.

For more information on your insurance options, please contact Jenn Negley, Vice President, Risk Strategies Company at 267-251-2233 or JNegley@Risk-Strategies.com.

Beware the Overtime Trap

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By Bruce Wood, Esq.

It’s no secret that there is a nationwide shortage of skilled medical professionals, particularly nurses and physician assistants, which has resulted in longer work weeks for many employees. Those staffing shortages will not be resolved soon and healthcare employers need to be careful to avoid running afoul of federal and state wage and hours laws governing the payment of overtime compensation.

There is a common misconception that all medical professionals are exempt from overtime compensation. The Fair Labor Standards Act (FLSA) provides an exemption from the Act’s minimum wage and overtime requirements for any employee employed in a “bona fide professional capacity”. To meet that test the employee’s primary duty must be the performance of work requiring knowledge of an advanced type in a field of science or learning customarily acquired by a prolonged course of specialized intellectual instruction.

Clearly, licensed physicians are considered professional employees. And so are registered nurses, nurse practitioners, physician assistants, and certain certified medical technologists. Licensed practical nurses and other similar health care employees, however, generally do not qualify as exempt professional employees because possession of a specialized advanced academic degree is not a standard prerequisite for entry into those occupations.

In addition to meeting the test of a bona fide medical professional, the exempt employee must also be paid on a salary basis; however, the salary requirement does not apply to those who practice medicine (e.g., physicians) and while it may be argued that NPs and PAs practice medicine (since they can diagnose and treat), the courts interpreting the FLSA have generally held that they do not.

Thus, if the NP or PA is compensated on an hourly basis, the FLSA requires the payment of overtime compensation for work in excess of 40 hours per week. In the absence of unusual facts and circumstances, the employment of an NP or PA on a fixed salary should be exempt from the FLSA overtime requirements.

Some healthcare employers may be tempted to try to avoid the statutory overtime requirements by structuring the hourly compensation arrangement as an independent contractor relationship rather than an employment relationship. Independent contractors are not protected by the FLSA. But the government is wise to attempts to skirt the wage and hour laws merely by calling a worker an independent contractor. The IRS, and more recently the Workers’ Compensation Board, have been aggressive in recharacterizing independent contractors as employees, with the imposition of fines, penalties and interest against the offending employer.

That is not say that there cannot be legitimate independent contractor arrangements. But the employer would wishes to use independent contractors should make sure that those contractors meet certain requirements: they should be truly independent with the right to control the means of their work; maintain their own insurance; have their own business cards and business identity; and preferably perform services for more than one medical practice.

What if the healthcare employer enters into an independent contractor agreement with the professional’s limited liability company (LLC) or corporation? Will that pass muster and thus exempt the hourly compensation from the overtime requirements?  The answer is a clear “maybe”. The courts will look to the economic reality of the arrangement and the designation of the contract between the parties will not be determinative. The fact that compensation payments are made to an entity rather than a real person, and issued a 1099 instead of a W-2, does not insulate the arrangement from potential recharacterization.

A medical practice that has hourly compensation arrangements with healthcare professionals without paying overtime compensation when earned creates not only an ongoing legal and financial risk but one that could derail the sale of the practice in the future. Hospitals, private equity venturers and other buyers conduct very thorough due diligence when undertaking acquisitions. Part of the due diligence will be an audit of employment practices to ensure that federal and state wage and hour laws have been complied with. If the potential acquirer believes that the medical practice has significant legal exposure from noncompliance, it may have leverage to extract large financial concessions, or in the worst case to walk away from the deal.

Bruce Wood is a member at CCB Law, a boutique law firm focused on providing counsel to physicians and healthcare professionals. He can be reached at 315-477-6292 or bwood@ccblaw.com.

Regional Reach

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Kathy Ruscitto

FIRST, I WANTED to share how much I enjoy feedback on these editorials. When people take time to agree or disagree, it improves both of our thinking. My perspective comes from my
experience. Thank you for sharing your experiences!

This column is on regional reach.

Living in the Adirondacks, I often receive phone calls from families in crisis — generally at night or on weekends. Care is limited to primary care in many rural areas, with no urgent care and little access to specialty care. “Where should I go?” is the most common question I hear.

Resident population has grown in the Adirondacks and many rural communities post COVID, and summer and seasonal tourism has also swelled throughout the region. The same thing
has happened in every tourist community around us.

When I get calls about where to go for care, I encourage them to call their primary care physician wherever they are and request a telemedicine consult. However, people often go to the local ambulance center, and the staff there may not be available if they are responding to a call. I have developed a shared list of urgent care centers in the region from Utica to Rome to Syracuse, and I also refer people to LivingADK (livingadk.org), an organization that
advocates for the region and maintains a list of regional resources.

Families travel routinely from throughout the ADK Park to Utica, Rome and Syracuse for orthopedic care, mental health care, cardiac care, emergency care and testing. They share with me the gaps they find and the difficulty they have in figuring out where to go. Sometimes they just pack up in the summer and return to their home communities hours away when they can’t figure out where and how to access care.

So my questions to your practice are these: Are you a local or regional resource? Do you offer screening clinics in rural communities? How do patients in rural communities, particularly
in the summer, know you are there? Does your marketing reflect your regional presence?

Conversely, I ask community leaders about how rural communities educate their residents and plan information around access to care for summer residents and tourists. Old Forge estimates it can go from 2,000 to 20,000 summer residents and tourists on a busy weekend. When there is an injury, the closest care is one to two hours away by car. 

The landscape in health care is changing, and patients are traveling further to access specialty care. Many large centers from the Mayo Clinic to Cleveland Clinic are offering telemedicine and access in ways that minimize travel.

What are the opportunities available through technology to expand your regional reach? How do regional screening clinics open up access for patients? Finally, are there innovative solutions for accessing care in tourist communities where an urgent care center could only be successful in peak season?

Think about reaching out to the regional organizations who provide info to summer visitors and new residents. I know LivingADK would love to hear from others not included in their database.

Thanks for all you do in serving these communities. 

Kathryn Ruscitto, Advisor, can be reached at linkedin.com/ln/kathrynruscitto or at krusct@gmail.com.

Further Reading
1. Emerging Stronger From the Crisis: What’s Next
for Regional Providers? (mckinsey.com/industries/
healthcare-systems-and-services/our-insights/emerging-strongerfrom-
the-crisis-whats-next-for-regional-providers)
2. How Standing Up Regional Markets Is Improving Access to Health
Care (health.mil/News/Articles/2022/01/11/How-Standing-Up-
Regional-Markets-is-Improving-Access-to-Health-Care)
3. Healthcare Access in Rural Communities (ruralhealthinfo.org/
topics/healthcare-access

CRAL’s Craig Zinserling Walks the Talk

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By Tami Scott

Perseverance is a character strength that most entrepreneurs would agree you must embrace to accomplish your dreams. This virtue is one that Craig Zinserling developed years ago, initially through watching and learning from his parents, Jack and Marcia. He would observe how they handled life – the good, the bad, and the ugly – just by sitting around their kitchen table and witnessing how they faced their challenges with a great attitude.

“You’re never given too much that you can’t handle,” he said. “My parents brought me up that way and [I’ve] been able to adapt that into my life.”

Zinserling, who founded CRAL Contracting, Inc., is celebrating the company’s 18th anniversary this year as an indoor air quality specialist. The “acronym” CRAL comes from combining Zinserling and his wife’s first names together: Craig and Lori. It’s perfectly fitting, too, since the company’s backstory involves a collaborative effort between the couple to get it started.

“I’d always watched my father in his business endeavors, and I always aspired to have my own business,” said Zinserling, despite having worked his way up to a vice president relationship working for a national environmental contracting company. “My wife Lori – she would encourage me. We had many, many long discussions trying to figure out how to make that leap even though we had a mortgage, three kids, and a couple of car payments – how do you pay all that?”

They persisted and they made that leap but not without a multitude of sleepless nights, seven-day workweeks, and attending many of his son’s soccer games with laptop in tow. As the sole “employee,” Zinserling wore many hats, selling, managing, and actually doing all the jobs on his own.

“In the beginning, it was hard getting established, but we made it through and we were able to establish a foothold through relationships we had built here in Syracuse, having grown up here my entire life,” Zinserling added.

CRAL now has two locations – one in Syracuse and one about an hour and a half west of Syracuse, in Rochester. Zinserling said the second location was a natural fit as he and Lori had lived there for some time, too.

The relationships he’s built over time have played critical roles in the building of CRAL and where it is today. For instance, once CRAL was established, its first customer was Crucible Steel in Syracuse – and that was in large part due to connections he made and maintained.

“If I have a friend who has a tax business or a barber shop, I’m giving my friend business even if it’s more money. I want to support my friends and those relationships that I’ve developed for over 55 years in Syracuse,” Zinserling said. “It’s a small town and doing work right and treating clients well will follow you.”

Loyal customers and a good-standing reputation also mean publicity in the form of “word of mouth.” When the pandemic began, Zinserling feared the worst.

“I think with any business owner, there was complete panic. From a business standpoint, I was wondering if I’d lose everything,” he said. “How do you close a business down and have no [money] coming in, and not being able to pay people – how will we survive?”

As the saying goes, perseverance pays off. Office staff continued to come to work and “didn’t skip a beat,” he remarked. The team was able to complete the projects for which they were hired and “like manna from heaven,” Onondaga County called CRAL for work. The first testing site had been set up in the inner city, but it needed disinfecting and sanitizing, of which CRAL is the expert.

“Our crews [went in] on a daily basis with specialized equipment. They were in full PPE, and we had HEPA air cleaning devices spread out throughout their facility and we were disinfecting and sanitizing around the clock,” Zinserling said.

Soon after, this service branched out to private businesses as well as nursing homes throughout NYS and downstate into NYC. “The nursing homes weren’t set up for isolation and that’s what we do. We’re very good at engineering isolation containment and we would contain an entire wing of these nursing homes and put them under HEPA negative air pressure and disinfect and sanitize around the clock.”

Other than a few calls here and there from a private business or nursing home, Zinserling said that type of work is essentially over. Regular services, such as mold remediation, lead abatement, and asbestos abatement, can again take the lead in project acquisition.

Giving back

Zinserling remembers what it was like to find and rent office space when he was just a budding business owner himself. About six years ago, he began pursuing real estate to purchase and eventually found a building that was reasonably priced but had a large footprint – 22,000 square feet. “I don’t need that much space,” he said. 

So, he came up with an idea that stuck and worked. He set up that building, and another one that he acquired, to be incubators for young local, minority entrepreneurs. “They rent a simple office from us and a space for their startup business.”

He’s had several renters leave to buy their own real estate to work from and he said it’s so fun to watch. “It’s absolutely a joy for me to watch these young guys and gals pursue their dreams and be successful.”

Zinserling also sits on the board for David’s Refuge, a local charity that over the years has grown exponentially. The nonprofit provides respite and other support to parents and guardians of children with special needs or life-threatening medical conditions. Warren and Brenda Pfohl formed David’s Refuge in honor of their son to encourage parents to keep pressing on. David was diagnosed with and battled Batten Disease for thirteen years.

“Parenting and marriage are difficult enough under regular circumstances and on top of being a full-time caregiver, it’s extremely difficult,” Zinserling said. “They really saw the need for caring for the caregivers.”

The organization provides caregivers with respite weekends, putting them up in nice places that also support the local community. To learn more about David’s Refuge, visit DavidsRefuge.org.

Zinserling’s steadfast spirit is a trait that, by the way he chooses to live his life, does not go unnoticed. And because he has a deep, personal, and meaningful sense of meeting life’s challenges with patience and perseverance, he wants to help those he works with daily to adopt that same attitude.

Now having grown a company to include up to 50 employees, professionally surviving a pandemic, and personally helping others through complicated life journeys, Zinserling is a stellar example of success.

And so are those who have helped him achieve his dreams.

“We have a core group of staff that has been here from nearly the inception. They are the backbone of the business,” Zinserling said. “Frankly, I am no longer needed. They are so talented and caring that they run the business.”

Are We Ready for 2023?

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Pierre Morrisseau

We have certainly been living through interesting times these past few years. Leadership has faced numerous challenges—some “once in a hundred years” events. Still, I am happy to report that the vast majority of our clients have thrived as they turned up their creativity and ingenuity, leaned their businesses, and opened their minds to new ways of operating. But as we all know; our work is never done. Change is the only constant, and leaders are looking cautiously toward 2023.

In a recent Gartner CEO and Senior Business Executive Survey, leadership’s greatest focus for 2023 boiled down to four “P’s”: People, Purpose, Prices and Productivity. I would agree and over the past year, we at OneGroup have doubled down in these areas as well as investing heavily in new technologies to increase our productivity and effectiveness in serving our clients in the new hybrid work environment.

While growth has always been the leading priority for any company to survive and thrive, we’re seeing from research and across our large client base, that there has been a dramatic shift in thinking toward the human capital that makes sustained growth possible. Our focus, like many others, has been on finding superior talent with superior work ethic. We have increased our training capabilities to ensure our employees have a clear path to growth and success with our company. We have organized our thinking and operations to recognize where an employee’s true talents and passion lie in order to maximize both retention and productivity. We have also focused intently on our workforce diversity and inclusion to allow us to take advantage of the broadest array of views. We feel strongly that these changes are allowing us to build a strong culture with a deep sense of purpose.

By way of disclaimer, as an engineer by education, I had always leaned toward data and process. Measuring data as gathered—a snapshot of time—allowed us to track our progress and amend our processes. However, limited our thinking to what “was” and prevented us from seeing what “could be” if we allowed for more flexibility and creativity within our workforce. I am very pleased to report that the results have been impressive. We certainly continue to capture and review data, but we now focus equally on how we can remove barriers to productivity and innovation. I believe this is creating a place that is more rewarding for employees and leading to better growth for our company.

Finally, the more troubling “P”—Prices—is a concern every leader is watching closely going into 2023. The Gartner survey showed that 62% of CEOs reported that inflation was expected to be high and to persist over the long term.

In our industry, we have been seeing steady increases in insurance premiums. There are many causes including higher overall prices for homes, automobiles, and repairs as well as increased risk in many areas including environmental, cyber-attacks, and supply chain woes to name a few. We see this putting a strain on business and draining dollars that could be deployed to increase productivity and growth. To combat insurance price volatility, we have expanded our risk analysis team, focus on identifying cost drivers and utilize our team of experts to find better solution. We also leverage our scale to offer clients more carrier options.  

Given all of the challenges we each share in our own industries, CEOs are an optimistic bunch. The latest Chief Executive CEO Confidence Index showed that CEO optimism soared 14% to nearly 6 in 10 believe that by this time next year, the country will be well into recovery. I, too, am confident that our work today will contribute mightily to our success in 2023.

I would love to hear your views and what you are navigating change. As always, I am happy to share what we are doing to grow our business.

Operational Excellence: A Journey

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By: James A. D’Agostino, CEO, MEP Center Director

As its name implies, continuous improvement is a never-ending process. Whether it is the need for greater sales, increased productivity, or anything in between, there is always something that can be improved upon. Continuous improvement can occur as a major event or transformation such as a Kaizen event, or it can occur through daily, gradual improvements with a Kata approach. When organizations realize successes with these continual improvement efforts, many will claim to have achieved some degree of operational excellence. But what is operational excellence, and what does a manufacturing organization look like once it achieves a level of operational excellence?

Operational excellence does not have a singular definition that is universally agreed upon, nor should it. Every company is different, so operational excellence may mean different things. Companies measure performance and success differently, and many also have different operational goals and objectives. Operational excellence is a mindset that embraces certain principles and tools to create sustainable improvements within organizations, and it is achieved when every member of an organization can see the flow of value to the customer. Employees should actively try to improve both the value and its delivery. However, from a high level, operational excellence can be broadly defined through the following core principles:

  • Focus on the Process: When mistakes happen, the natural human reaction is to blame the operator. Deming, anyone? However, when we take a moment to analyze the issue, we should question why the process allowed the operator to perform in the manner that resulted in the mistake. We should strive to assess what part of the process the error occurred in, and then make the necessary process changes to try to achieve the desired outcome.
  • Promote Scientific Thinking: As we discussed recently with the subject of Toyota Kata, innovation comes from rapid experimentation and learning. By systematically exploring new ideas, an organization will encourage employees to do the same without fear of failure.
  • Emphasis on Value Streams and Systematic Thinking: Organizations must fully understand customer needs to create value (i.e., what customers are willing to pay for). Organizations that stop delivering customer value are not sustainable over time. In addition, systems contain many different interconnected parts that work together. It is critically important to understand relationships between each part to ultimately make better decisions that will positively impact customer value.
  • Flow and Pull: The goal of every organization should be to provide the utmost value to its customers. Interruptions and work stoppages create inefficiencies (i.e., waste), so organizations should ensure that processes and workflows are continuous. Hand-offs from one operation to the next should be crisp and tight.
  • Quality at the Source: Excellent quality can only be achieved when every part of the process is completed correctly. Workstations and processes should be structured and organized to allow potential problems to become visible immediately. When mistakes occur (and they will), work should be stopped immediately to correct the mistake before continuing, and time should be taken to understand what was learned by the mistake.
  • Respect All Individuals and Lead with Humility: Respect is a two-way street. One of the best ways to demonstrate respect for your employees is by involving them in continuous improvement efforts, especially those that affect them. This will lead to empowerment and greater engagement. Leaders should always seek to exercise humility, which involves a willingness to listen. Good leaders should also always give credit where credit is due.
  • Aim High: While perfection may feel unattainable, that does not mean that an organization should not strive for it anyway. By setting lofty goals and expectations, an organization creates a different mindset and culture.
  • Clear and Consistent Goals and Communication: Employees should continually understand and be aware of the goals and objectives of the organization, along with their progress towards meeting them. This will keep the organization aligned in its purpose from top to bottom.

Overall, operational excellence is not just about reducing costs or increasing productivity in the workplace. It is about creating a vibrant company culture that will allow you to produce valuable products and services for your customers and achieve long-term sustainable growth. Operational excellence is a journey that involves applying the right tools to the right processes at the right time. When this happens successfully, the ideal work culture is created where employees are provided for in a way that enables them to stay empowered and motivated.

Does your organization look and perform like this already? If so, job well done – you can pat yourself on the back! If not, do not fret. TDO’s team is fully certified to help manufacturers define and achieve operational excellence at all levels. Reach out today to learn more and schedule a free consultation!

WILL THEY TAKE MY HOUSE? (AN ARTICLE ABOUT LONG-TERM CARE PLANNING, NOT BANKRUPTCY)

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By Jason D. Nickerson

The topic for this article came through a request that focused on Medicaid. However, I decided to expand the topic to include Long Term Care Planning because this is an extremely robust topic, as you will see.  The question that serves as the title of this piece illustrates how much confusion lies in this area of Wealth Management.

Let’s start with the ominous “They”.  Who are “They” and why are they taking people’s homes?  How does this link to me getting older and not having the ability to take care of myself?  While this is a very common concern, no one is in fact going to come and take your home.  This is a myth – that when you are unable to care for yourself, someone will show up, kick you out, and take ownership as payment.  This does not happen.

Instead, Long-Term Care generally happens in 3 phases:

  1. In-Home Care: Most people prefer to stay in their own home if they can by hiring people to come in part-time and help with daily activities.  There are two ways to pay for this: out of pocket or insurance. 

2.      Assisted Living: A location that people rent that includes some level of help with daily activities and onsite medical treatment.  Again, paid for out of pocket or with insurance.

3.      Nursing Home:  This is the level of care needed when you cannot be alone or need help with just about any daily activities.  There are three ways to pay for this: out of pocket, insurance, or Medicaid (also a form of insurance).

Medicaid pays for nursing home care when people cannot pay for it themselves or don’t have long term care insurance.  As stated earlier, they do not come to take your home.  Medicaid is not looking to be a real estate investor.  Rather, the value of your home can be factored into the assessment of your ability to pay for your care through assets and income.

Before we go much further, this is not an article about how to make yourself look “poor” to qualify for Medicaid.  There is a great debate over the ethics of these efforts and we will leave that discussion for another article.

The common questions we get asked are “What can I do to protect my house from the nursing home?” or “Do I need Long Term Care Insurance?”  At John G. Ullman and Associates, we enter these conversations with clients by asking one simple question (after preparing a detailed personal net worth statement); “Do you want to protect any of your assets for your heirs?”  If the answer is yes, then we need to discuss the different forms of insurance that may be available.  If the answer is no, then that is usually the answer for whether insurance is needed.

We then go on to one of the great philosophical statements: In order to get something, you have to give something up.  I believe the root of this should be credited to author David Levithan, different words, same meaning.

If you want to protect your assets, you can either spend money on insurance, or give it away to your heirs now (with no future benefit coming back to you).  If you give it away now, it’s not yours.  The protection you seek may not deliver what you would want for yourself for care going forward.  If you want top-notch care, you will need to give up some level of protection of assets for heirs and use it instead to pay for insurance and/or your care.

As this topic is extremely robust, my goal was to present a mental model for approaching it with your advisor, be it financial or legal, rather than lay out specific strategies.  That could take up a single volume of this publication all its own.  If you do not have a professional you are working with and need to on this topic, please contact us for a non-commercial (meaning free and we won’t sell you anything) discussion and we can get you started down a good path. 

So will “They” take your home? No, but you should still be preparing for future health care costs. It is not an enjoyable topic to consider or discuss, but you should not just table it for the future because the future might arrive sooner than you expect. You have options; take the time to explore them. In the end, whether you want to protect assets by using long-term care insurance or prefer to spend your own money is a choice entirely up to you. 

David’s Refuge, Pierre Morrisseau, and the Pineview Run Celebrity Challenge

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By Christine Corbett, Director of Philanthropy, David’s Refuge

David’s Refuge is a growing local non-profit with a unique mission to provide respite, resources and support to parents and guardians of children with special needs or life-threatening illnesses in an effort to combat caregiver burnout.  They do this through an array of Respite, Wellness and Community programs which remind caregivers they are not alone, what they do matters, and that God and this community loves them.

In 2021, when planning for a unique event at Pineview Run & Country Club, Pierre Morrisseau, CEO of OneGroup wanted to include a charity component, and reached out to the team at David’s Refuge to explore the idea. When asked where the idea came from Pierre shared “I joined Pineview and realized quickly how great it is to have this right in our backyard.  The club really focuses on family fun and I think more people need to enjoy the sport of driving on a track. I’ve supported David’s Refuge for a long time and knew David personally.  It’s an organization that is focused on supporting families, so I thought why not put the two together?”

At that point, The Pineview Run Celebrity Challenge was born, with local friends signing up to be trained on driving the 1.1-mile racetrack, with a light-hearted race day scheduled for 1 month later.  During that month, drivers would raise at least $1,000 to support the mission of David’s Refuge.  As a competitive advantage, for every $1,000 that drivers raise, one tenth of a second is taken off their final track time. This means that the slowest drivers still have a great chance of winning the race and claiming bragging rights for the year.

Pierre is not just the brainchild of this event, but he is also a celebrity driver.  When asked why he chose to drive in the Pineview Run Celebrity Challenge, Pierre shared “It is a tremendous organization.  I have witnessed firsthand the relief, joy and satisfaction this mission brings to caregivers.  The rejuvenation it gives so that parents can bring that energy back to those they care for. It’s a gift that’s so important to give.” Pierre has succeeded in raising more than $14,000 for his races, all while introducing new friends to the mission of David’s Refuge.

The last two years have featured 24 amazing local “celebrities” in total and generated more than $75,000 in support of caregivers.

The 2023 Pineview Run Celebrity Challenge will take place in the Spring, if you are interested in joining as a celebrity driver, please contact Christine Corbett, Director of Philanthropy at David’s Refuge, at christinecorbett@davidsrefuge.org. 

Who Advocates for the Construction Industry?

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Earl R. Hall, Executive Director – Syracuse Builders Exchange

Politicians.  Lobbyists.  Elected officials.  Legislation.  Laws.  Regulations.  Do those words generate a positive or negative connotation?  While answers will vary depending on individual circumstances or experiences, one thing is for sure:  They all impact how the construction industry functions and influence decisions of construction industry employers. The Syracuse Builders Exchange chooses to advocate and educate in an effort to support a position which is most advantageous to the industry.

Advocacy efforts happen every day, either by special interest groups, lobbyists or the general public, in an effort to influence politicians or policy makers.  But who is representing the interest of the construction industry in both Washington, D.C. and in Albany?  The answer depends on the position of subject matter and how much money one has to hire lobbyists to deliver a persuasive argument as to why legislation should be supported or opposed. 

Although some construction industry Associations have lobbyists, many local construction industry Associations and state-wide Associations do not.  In both cases, however, there is a coalition of industry Associations which generally work collaboratively in an effort to identify items of mutual importance to the industry, and then develop a strategy to advocate a position that the various organizations can agree with. 

Examples of advocacy provided by construction industry Associations may include:

  • Meeting with local and state elected officials in an effort to directly deliver a position of support or opposition, (example – Assemblyman Al Stirpe in central New York).
  • Meeting with appointed officials to mitigate or resolve issues impacting employers and/or the industry (example – Shaun McCready, NYS Department of Labor Director of Public Work).
  • Collaborating with like-minded Associations to deliver a “strength in numbers” campaign, supporting or opposing pending legislation, or urging the Governor to veto potential legislation (example – Associated General Contractors of NYS, Builders Exchange of Buffalo & Western NY, Eastern Contractors Association, Building Industry Employers of NYS, etc.).
  • Working with lobbyists to create positions of strength in an effort to effectuate change or educate (example -Hill, Gosdeck & McGraw, LLC).
  • Working with staff of elected officials to resolve industry issues or advocate for a position (example – Senator Charles Schumer).

While the Syracuse Builders Exchange does not have a lobbyist, nor do we pay for lobbying services, the Association does advocate for construction industry employers and the industry in general.  Representing the interests of the industry is critical in defending our industry from poor legislation, governance or regulations derived in Washington, D.C. or Albany.  And while many Associations do not have the financial resources to compete with special interest groups, the Syracuse Builders Exchange will continue to partner with like-minded construction industries Associations in an effort to educate elected officials on issues of importance and to advocate for our employers and the industry in general.

Nappi Wellness Institute: Improving Healthcare Outcomes for Vulnerable Populations in an Accessible, Supportive Environment

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By Daniel K. Brantley

Tuesday, October 25, 2022

Upstate University Hospital’s soon-to-open Nappi Wellness Institute introduces a new era of health care with a suite of patient-centered ambulatory services and provider benefits in one location.

The area shown under construction will transform into a light and bright reception area.

An increasing amount of data indicates an imperative need to improve healthcare equity for vulnerable patient populations — an issue that’s been evident for years — and hospital systems across the country are attempting to level the field. With a $70 million grant from the New York Department of Health, a $75 million bonding opportunity to match funds, and an $8 million naming gift, Upstate University Hospital has been working on a solution, and that work is about to come to fruition.

Scheduled to open in early 2023, the Upstate Nappi Wellness Institute is a five-story, 200,000-square-foot outpatient facility that will integrate multiple primary and specialty health services and a bevy of unique amenities under one roof. The new Institute is expected to remove many of the barriers that send patients to the hospital instead of getting timely, appropriate care in the lowest acuity setting.

As the new Institute gets underway, Upstate University Hospital anticipates fewer unnecessary emergency visits and inpatient stays, ultimately leading to more cost-effective healthcare delivery and improved quality of life for vulnerable community residents. Combined, the benefits offered meet the qualifications of the state’s Delivery System Reform Incentive Payment (DSRIP) program, an initiative aimed at restructuring Medicaid’s healthcare delivery system and reducing unnecessary hospital use by 25% over five years.

“The COVID-19 pandemic catalyzed a transformation in health care that was talked about for a long time but only dabbled in,” says Amy Tucker, MD, MHCM, Chief Medical Officer at Upstate University Hospital. “Fortunately, we’re ahead of the curve with the Institute, which introduces a new model of care focused on wellness.”

Left to right: Amy Tucker, MD, MHCM, Marylin Galimi, Chief Operations Officer, Marisa Desimone, MD, Nancy Daoust, EdD, FACHE, LNHA

“The remodeling of care to focus on wellness is not just promoted at the Institute — it’s embraced. Everything about the building and the services offered centers around helping people stay well, vibrant and functional.”
— Amy Tucker, MD, MHCM, Chief Medical Officer, Upstate University Hospital

Built for Optimal Health

An integrated model of care guided the design and construction of the Nappi Wellness Institute. And following the WELL Building Standard, the Institute’s design and layout will promote the good health of patients, visitors, clinicians and staff alike.

“We wanted to change what people perceive as health care to be proactive and focused on wellness,” says Marylin Galimi, Chief Operations Officer at Upstate University Hospital. “We didn’t want another facility with clinics where you simply come in and wait for an appointment. We wanted to build something that represented the idea of caring for your body and your family.”

WELL Building Standards include the following:

  • Air: The Institute features filters that circulate 100% of outside air throughout the building.
  • Comfort: Convenient break and lactation rooms allow providers to decompress or tend to personal matters in spaces designed with an intentional lack of work-related furniture or equipment.
  • Fitness: The interior of the building has a walking loop that includes stairs, so team members can get some exercise without leaving the grounds.
  • Light: Large windows bring ample natural lighting into waiting areas, which line the perimeter of the Institute. For patient privacy, patient rooms are inside the pathway, and staff members can control the light in these and other interior rooms.
  • Mind: Calming, digital art on walls and earth-tone colors serve to provide a calming environment for all patients. Outdoor seating surrounded by trees and lush gardens, and a meditation labyrinth provide additional on-site havens.
  • Nourishment: Family-style break rooms with large-capacity refrigerators and a café bathed in natural lighting offer patients and staff members wholesome meals featuring fruits, vegetables, lean proteins and whole grains.
  • Water: Hospital-quality water filtration ensures all water sources are properly filtrated. Handwashing stations throughout the Institute allow easy access within and outside of clinical spaces.

As a LEED-certified building, the planet’s health was also considered during its planning and construction. The energy-efficient space encourages recycling all eligible materials and appropriate disposal of debris. Supplies will be purchased locally or regionally when available and appropriate.

Upstate Nappi Longevity Institute Groundbreaking

Easier Access to Primary and Specialty Care Services

The Institute will be home to a variety of primary and specialty care experts that can reach further than any single clinician or specialty could. Before the Institute was established, Upstate University Hospital healthcare services were provided in numerous locations spread throughout the area, each with its own medical directors, nursing and business leadership in place. These healthcare professionals will still retain their governance while working at the Institute, though some will share clinical space. Everyone will work together to provide more efficient, comprehensive patient care.

Patients who visit the Nappi Wellness Institute will have access to:

  • Adult and pediatric medicine
  • Alzheimer’s disease care and research, which is a special focus of the facility (see sidebar)
  • Center for International Health
  • Connect Care/Upstate After Hours
  • Endocrinology
  • Family medicine
  • Geriatric medicine
  • Inclusive health services
  • Integrated care
  • Internal medicine
  • Joslin Diabetes Center
  • Laboratory
  • Osteoporosis care
  • Nutrition counseling
  • Outpatient pharmacy
  • Palliative care
  • Radiology
  • Social work

Should hospitalization or emergency services be necessary, a pedestrian bridge gives immediate access to Upstate University Hospital. The bridge also allows Institute clinicians to follow up with hospitalized patients in a timely manner.

“We want to be of service to the community and I think we can do that with this facility — not just with the building, which is special, but with all of our services coming together in a cohesive, comprehensive way.”
— Nancy Daoust, EdD, FACHE, LNHA, Chief Ambulatory Officer at Upstate University Hospital

Services for Behavioral and Social Well-Being

Behavioral health services will also be available on-site. In the event patients present with behavioral healthcare needs, they can visit each clinic’s on-site behavioral health professional — a valued and much needed development for clinicians. For example, the Joslin Diabetes Center, the largest clinic within the Nappi Wellness Institute, is housed on the fifth floor, and behavioral health is likely to be an important part of care.

“Diabetes is often a chronic, lifelong condition that carries a heavy mental health burden for many patients,” says Marisa Desimone, MD, Associate Medical Director of the Joslin Diabetes Center. “Beyond diabetes, lots of people are struggling after spending two and a half years facing the worldwide stressors of the pandemic and other issues.”

The Institute also will provide educational spaces for well-being classes, nutrition counseling, cooking lessons, community lectures and other health and wellness learning opportunities. As equity in health care takes center stage, social determinants of health have become a major focus. According to Dr. Tucker, population health factors guided the creation of the Institute and its services, including drop-off, valet parking and covered bus stops across the street. Upstate Ambassadors will personally greet patients at the door and arrange for an escort to take them to appointments if needed.

“Those touches are a big deal,” Dr. Tucker says. “For vulnerable patients, these can make the difference between coming to a healthcare appointment and not being able to do so.”

Sam and Carol Nappi are joined by family members as well as by Upstate University Hospital President Mantosh Dewan, MD; Eileen Pezzi, MPH, Upstate Foundation; and David Amberg, PhD, Upstate Research, as they paid a recent visit to tour the building while it’s under construction. The gift from Sam and Carol Nappi — the largest ever received by the Upstate Foundation and Upstate Medical University — will be used to expand the building’s services related to neurosciences, including a focus on Alzheimer’s disease. The Nappi Longevity Institute is named in recognition of the couple’s philanthropy.

Feedback Matters

Though population health inspired the Institute, those who will be working there played major roles in ensuring it also met provider needs. Hundreds of individuals assisted in the development of the Institute, including a physician advisory committee which worked alongside nurses, business and marketing executives, hospital administration, security personnel, and more.

The physician advisory committee’s influence is evident in the exam rooms. When physician leaders examined the desks designed for exam rooms, they agreed they were aesthetically pleasing but immediately recognized they weren’t functional. That physician feedback helped the architects create an updated plan featuring large, half-moon-shaped desks that allow clinicians to face patients while talking to them. Additionally, computer screens mounted on the desks move easily to meet the specific ergonomic needs of different providers.

In the geriatric clinic, physicians recommended table height adjustments to make it easy for wheelchairs to fit underneath. Plans to develop mobile workstations in the pediatric area changed when providers noted the potential risk for children climbing on and damaging them.

“Patient care comes first — 100% — always will. [You] can’t go into health care without that outlook. It has to come first.”
— Marisa Desimone, MD, Associate Medical Director, Joslin Diabetes Center at the Nappi Wellness Institute

Technology Upgrades

To ensure continuum of care between providers at the Nappi Wellness Institute and other Upstate locations, all services tie into the Epic electronic medical record system. In place for years, this connectivity allows providers to communicate seamlessly with one another and grants patients access to their health information and appointments via MyChart.

The Institute plans to leverage additional Epic functionality to benefit all users.

“The Institute represents the clinic of the future,” says Nancy Daoust, EdD, FACHE, LNHA, Chief Ambulatory Officer at Upstate University Hospital. “We’ve had great talks with Epic, and we hope to be a beta test site for them to test upcoming Epic functionalities.”

In addition to Epic, real-time location scheduling (RTLS) technology will remedy any scheduling and patient-flow issues. With RTLS, clinicians on one floor can identify available equipment and exam space on another to make use of them as needed. These and other high-tech functionalities will enhance the physical proximity providers experience at the Institute.

“Being in the same building will facilitate even closer collaboration when we pass one another in the hallway, garage or elevator,” Dr. Desimone says. This opens the door for clinicians to “strike up a conversation and brainstorm how to meet a patient’s needs.”

Prepared for Growth

The Nappi Wellness Institute is presently large enough to meet a variety of health needs in the community, but Upstate administrators also had the foresight to plan for growth. The Institute currently has five floors but can accommodate an additional three stories if clinicians, administrators and other team members see a need.

“We want to decant all ambulatory services out of the hospital, which is cramped for space,” Dr. Daoust says. “Doing this presents us the rare opportunity to scope out incoming practice needs and ensure they have more space that allows them to grow further in the future. Think about the impact we can have on a real-time basis instead of a patient having to wait in the ED.”

To ensure the appropriate allocation of areas within the hospital and stand-alone clinics, Dr. Daoust and others are closely monitoring department communications so they can successfully meet future requirements and build on their success.

“By making services accessible and convenient, co-located in a one-stop shop and affordable, we’re positioned to move the needle on our community’s health,” Dr. Tucker says. “The services we offer will be robust, in addition to a very nice experience for patients who go to the Institute, and for the clinicians and staff who practice there. We’ll have a model that is welcoming and easy for referring providers as well.”

A Naming Gift of Lasting Impact

The naming gift from Sam and Carol Nappi will be used to provide services related to the neurosciences inside the new Nappi Wellness Institute, including a special focus on Alzheimer’s disease. The Nappi Wellness Institute is named in recognition of the couple’s philanthropy.

“The Nappi’s support, with its focus on Alzheimer’s disease and brain health, is a down payment on creating healthy futures for all of us as we age,” says Sharon Brangman, MD, Distinguished Service Professor and Chair of Geriatric Medicine at Upstate University Hospital, and a former president of the American Geriatrics Society.

“Sam and I want to continue our commitment to Central New York in both deed and funding,” Carol Nappi says. “We will work with Upstate Medical University to build a world-class facility, assemble a renowned medical team and fund groundbreaking research.”

“We’re encouraged and excited about the 21st century vision the team at Upstate Medical University and the Upstate Foundation have shown in their commitment to medical research and proactive medical care,” Sam Nappi says. “Carol and I look forward to working with them.”

The Nappis have a long history of supporting local causes, focusing much of their philanthropic initiatives on medical research and community medical care. Sam Nappi is founder and chairman of Alliance Energy. Carol Nappi, a former psychiatric therapist at Community General Hospital, now Upstate Community Hospital, is active with numerous local and national charitable organizations. She is a 2000 Jefferson Award winner, a national recognition honoring community and public volunteerism.

Visit upstate.edu/nappi-wellness-institute to learn more about the groundbreaking approach to care at the Nappi Wellness Institute.