Gators in the City

With three colleges, Shands Jacksonville, the UF Proton Therapy Institute and dozens of clinics in Jacksonville, The Gator Nation has a high profile on Florida’s First Coast

By April Frawley Birdwell

Dr. Linda Edwards visits patient Dorey Hill in the Jacksonville Health and Transition Services clinic, which helps teens make the jump to adult care./Photo by Jesse S. Jones

Just minutes from the skyscrapers that dot Jacksonville’s skyline and the river that snakes through the city, UF’s Jacksonville campus is its own bustling metropolis of gleaming white brick buildings.

Though the original hospitals where the campus now stands date back to the 1800s, the area evokes a sense of shiny newness, with the UF Proton Therapy Institute, Shands Jacksonville and assorted glass-fronted buildings all within walking distance of each other.

A view of Shands Jacksonville/Photo by Jesse S. Jones

The look of the campus perhaps reflects the hopefulness and cheery camaraderie of the people who work there. Known best throughout the community for Shands Jacksonville, which boasts 70 specialty services and the only Level 1 trauma center in the area, the central campus is also home to the College of Medicine-Jacksonville, a College of Nursing campus and a College of Pharmacy campus.

UF’s roots in Jacksonville extend officially back to 1969, when a graduate medical education program in Jacksonville, known as the Jacksonville Health Education Program, was incorporated into the UF Health Science Center, says Robert Nuss, M.D., dean of the regional campus and associate vice president for health affairs. This assimilation would eventually lead to the establishment of a regional College of Medicine campus in Jacksonville.

Now, however, UF&Shands’ ties extend throughout the sprawling city. Thirty-seven practices are located across town, including the new multispecialty Emerson Medical Plaza. And there are plans to develop an outpatient center near the airport, potentially with inpatient beds down the road, said Jim Burkhart, president of Shands Jacksonville.

“Part of the strategic plan is to realize that while the Eighth Street campus is the hub of education and academic activities, there needs to be expansion off this site because health care, like politics, is all local,” Nuss says.

Because of the size of the city — it’s the largest by area in the country — the Jacksonville campus is naturally a different place than the Health Science Center in Gainesville. With a larger population, there is a higher volume of patients from the community. In the last fiscal year, UF doctors in Jacksonville saw 616,000 patients, Nuss says. The College of Medicine-Jacksonville also does not house basic science departments, although its research dollars have climbed to about $20 million.

UF and Shands in Jacksonville also have a longstanding relationship of working very closely, something Nuss thinks goes back to when the hospital, college and physician practice plan were struggling financially. After two bad years that resulted in $64 million in losses at the hospital, the financial turnaround began in 2002.

“The turnaround would not have been possible without that strong relationship,” says Burkhart, who came to Shands Jacksonville as a consultant in 2001 to help stem the financial downslide and was appointed administrator in 2003. “We do everything together, even capital and strategic planning, and we have been that way at least since I have been here.”

The campus has led initiatives, such as implementation of electronic health records, which have been part of physicians’ practices there since 2003. The Jacksonville campus also is home to one of the largest medical simulation centers in the country, located on two floors in old emergency room and operating room space. And, of course, Jacksonville has one of only nine proton therapy facilities in the country.

This month, The POST brings you an abridged collection of stories about just a few of Jacksonville’s highlights.

Building nurse leaders

Jesse Forshey is getting his Doctor of Nursing Practice degree at the College of Nursing in Jacksonville./Photo by Jesse S. Jones

In hospitals and health-care agencies across Jacksonville, many nurses in top leadership positions have one thing in common — they earned their graduate degrees from the University of Florida.

In Jacksonville.

“This campus was really set up to bring graduate nursing education to the Jacksonville metropolitan area, which it has done,” said Andrea Gregg, D.S.N., the campus director of the UF College of Nursing in Jacksonville. “The nursing community knows about it, but I don’t know how much the community at large does. I think it is one of the best-kept secrets in Jacksonville.”

A 2010 Institute of Medicine and Robert Wood Johnson Foundation report on the future of nursing called for more nurses to pursue graduate education. Highly educated nurses are needed, the report states, to address the complex needs of today’s patients and to create nursing leaders to help improve health care systems.

But it is the rare nurse, Gregg says, who can take time off work to pursue graduate education. Nursing education needs to come to them. Enter the UF College of Nursing, which was established in Jacksonville 30 years ago. Although there are other graduate nursing programs in Jacksonville, UF was the first (and only) to offer a Ph.D. in nursing and was the first to offer the new Doctor of Nursing Practice degree, Gregg said.

“UF wouldn’t have been an option for me if it wasn’t in Jacksonville,” said Jesse Forshey, R.N., a UF College of Nursing student who began pursuing his Doctor of Nursing Practice degree in 2009.

The Jacksonville campus is also home to the college’s nurse-midwifery program. UF nursing undergrads can rotate there to study with the midwifery faculty as part of their senior experience. Distance classrooms also enable faculty members to teach students on both campuses.

Jacksonville’s regional medical campus

After rotating through the Jacksonville campus during her third year of medical school, Kristina Betters realized something about herself. She wanted to work in a big city.

“Everywhere I applied for residency is a big city, which is something I never would have thought,” she says. “Jacksonville is a big city and you learn a lot by going there. I think it makes our medical and physician assistant students stronger because we are prepared to work in any setting, a big city or a mid-sized city like Gainesville.”

Many Jacksonvillians (and Gainesvillians for that matter) may not realize it, but all UF medical students complete some of their training at UF’s Jacksonville campus. Students rotate through the hospital and clinics there during their third and fourth years of medical school. Students spend a minimum of three weeks in Jacksonville, though some students are there for as much as 90 percent of their clinical training, said Frank Genuardi, M.D., M.P.H., an associate professor of pediatrics and associate dean for student affairs at the College of Medicine-Jacksonville.

“We are in a large city,” Genuardi says. “There are a lot more people and more opportunities for students to see a high volume of common things. For example, we deliver a lot more babies here. And at least half of students do their emergency medicine rotation here.”

For students, being in Jacksonville gives them an additional opportunity to rotate through a children’s hospital — UF physicians provide half the staffing at Wolfson Children’s Hospital — and work in Department of Health clinics, too.

Betters completed seven rotations in Jacksonville. And she got her wish about working in a big city. She will begin her pediatrics residency at Emory University in Atlanta this summer.

Not a kid anymore

Dorey Hill was diagnosed with diabetes two years ago./Photo by Jesse S. Jones

In August, Dorey Hill will officially be an adult, old enough to vote or get a full-time job, if she wants. At 18, she will be responsible for her own health care, too.

Diagnosed with type 1 diabetes two-and-a-half years ago, Hill has been preparing for that eventuality for the past year as a patient at UF’s Jacksonville Health and Transition Services clinic, also known as JaxHATS.

“It gets you ready for adult doctors,” said Hill, a high school junior. “It’s more independent. They try to teach you to take care of your own disease and not rely on the people around you.”

After conducting a needs assessment in the Jacksonville community several years ago, UF leaders realized many adolescents with chronic illnesses were falling through the cracks, not making the transition between pediatric and adult care, said David Wood, M.D., co-medical director and founder of the program. Linda Edwards, M.D., a UF internist, is also a co-medical director and Hill’s doctor.

In the past, children with many chronic diseases did not always live to adulthood, creating a complex problem for adolescents graduating from pediatric care. Adult physicians are not trained to deal with the diseases they face and while pediatric specialists understand the diseases, they can’t manage the other problems teens encounter as adults.

The JaxHATS program helps teens and young adults with chronic health or mental health conditions prepare to take care of themselves, handle insurance issues and interact with adult health care providers. Living with and controlling a chronic illness can be a challenge for young adults, who are trying to figure out their lives and gain independence at the same time.

“The adult health care system is not prepared to treat these emerging adults,” Wood said. “Young adults with chronic diseases are quite different than elderly people with chronic diseases.

“We serve as a medical home for them and try to prepare them for the adult health care system.”

Typically, patients stay at the clinic for two to three years before making the leap to adult care.

“I know how to take care of myself and adjust my insulin,” says Hill, who grew up watching her father manage diabetes, too. “I feel pretty confident.”

Powered by protons

Ruffin Price was treated at the UF Proton Therapy Institute for a clival chordoma./Photo by Jesse S. Jones

Leaning across the table, Ruffin Price points to the faint pink spot on his forehead.

“I get radiated in five fields,” he says. “You can see this spot, then there, then there is two on the back of my head and two on the side. I still get up every morning and run, I kept my normal routine.”

Diagnosed with a rare brain tumor called a clival chordoma, Price began a course of proton therapy at the UF Proton Therapy Institute in January, after three surgeries to diagnose and then remove the tumor from his brain.

The UF Proton Therapy Institute in Jacksonville is one of just nine such centers across the country offering this precise dose of radiation, which targets tumors while sparing healthy tissue.

More than 100 patients a day are treated at the center, and for those with tumors in sensitive locales, such as the brain, this targeted radiation is, literally, a lifesaver. A typical dose of radiation kills tumor cells but can also harm surrounding healthy tissue, which could prove particularly damaging in the brain. Proton therapy, on the other hand, wreaks its havoc when it reaches its target inside the tumor, leaving surrounding tissue and organs alone.

The protons are powered by a 440,000-pound cyclotron, which sends protons out at 62 percent the speed of light. The protons are funneled into “gantries,” where patients receive treatment.

Price had never heard of proton therapy and with two children, he was hesitant to leave his home in North Carolina for Jacksonville. But, to his surprise, the center wasn’t at all like what he imagined.

“You come in thinking you are walking in to hospital, with sad people everywhere,” he says. “But you sit out there for an hour and it’s totally the opposite. And when you go in the gantry, you feel like you are the only patient in the whole place.”

Defeating disparities

UF medical student Ricardy Rimpel (left) and Dr. Kenyatta Lee (right) visit with patient Rose Bowers at the UF Soutel Family Practice and Pediatric Center./Photo by Jesse S. Jones

The most densely populated area of Jacksonville lies in the heart of the city, stretching northwest from the sparkling lights of downtown to Interstate 295. About 80 percent of the people who live here are minorities, and the area has the lowest household income in Jacksonville. Worse yet, the region has the largest number of HIV/AIDS cases, the highest teen birth rate and infant mortality rate, and the highest number of hospital visits for asthma and diabetes.

Yet, patient-by-patient, the Jacksonville Urban Disparity Institute is working to change these statistics. Led by UF College of Medicine-Jacksonville doctors from the department of community health and family medicine, the program is working to provide medical homes for patients in the area, including those with little or no insurance.

“We have decreased the number of uninsured visits to the ER by 14,000 a year,” said Eric Stewart, M.D., medical director of the UF Commonwealth Family Medicine and Pediatric Center and director of the Jacksonville Urban Disparity Institute.

The program is vast, with community primary care clinics sprinkled throughout the area, three disparity clinics and a cadre of assorted support programs geared to help patients manage chronic illnesses, get free prescriptions, obtain insurance coverage and improve their lives.

“We are providing a medical home that gives a more holistic approach to caring for individuals,” said Cheryl Kinson, an administrator for the clinics. “We have all sorts of resources we can utilize.”

Disparity clinics are held at three different locations throughout the week. Geared toward those with little to no insurance, these clinics help patients manage chronic illnesses such as diabetes, hypertension and congestive heart failure. Their conditions and lab results are tracked and monitored, in an effort to catch problems before a patient winds up in the emergency room, says Yolonda Nunn, A.R.N.P., who oversees the disparity clinics. Caseworkers also help patients obtain better coverage in case other health problems arise.

“People who don’t have insurance can come here and be seen for free. It is not just people with no insurance,” said Kenyatta Lee, M.D., a clinical assistant professor of community health and family medicine. “Seventy percent of the people who go (to the disparity clinic) next door have insurance. It is the underinsured people who cannot afford copays. When you increase access you improve quality.”

The structure of the primary care clinics also helps keep patients out of hospital beds. In 2010, the National Committee for Quality Assurance designated the clinics as patient-centered medical homes. Lee described the medical home model as an operating system for medical practice. Doctors’ offices use technology and systems, such as disease registries, to track and follow-up with patients.

“Most of our health care costs in this country are from chronic disease care. Ambulatory practice does not have systems in place for chronic care, we have an acute care model — when people come they come,” Lee says. “The medical home model is an operating system you install within your practice to better manage chronic diseases. It is a package of evidence-based systems focused on chronic disease care.”

The clinics, programs and classes offered through the institute are also geared to be accessible to patients, with clinics open after hours, on Saturdays and in locations across the community.

“There is no reason why a person in Jacksonville, Florida, Duval County does not have access to treatment,” Kinson says. “There is no reason.”

The College of Pharmacy

Juan Hincapie-Castillo thought about pursuing pharmaceutical chemistry in his native Colombia. But it wasn’t exactly what he had in mind. He wanted to work with patients.

So, after moving to Jacksonville in 2007 to study English and take college classes, he went to an open house at the College of Pharmacy-Jacksonville. He loved it. In 2009, he enrolled as a first-year pharmacy student.

“I really like the medical field, you get to interact with patients and be part of the health care team. You can use your knowledge — we study for four years — to help people,” Hincapie-Castillo says.

Jacksonville is home to one of the four College of Pharmacy campuses located across Florida — the others include Gainesville, Orlando and St. Petersburg. The campus opened in 2002 and now has 200 students, three full-time faculty members and 15 associated faculty members.

Students take many of their core courses online — lectures are taped in Gainesville and put online the same day — and visit campus for tests, panels, case studies and labs, Hincapie-Castillo says. UF pharmacy students complete their clinical rotations across Florida, and, in some cases, around the world.

Jacksonville may be the smallest pharmacy campus, says Carol Motycka, Pharm.D., the campus director, but this allows its students and faculty to be close. Another bonus for Jacksonville students, she says, is the college is located at Shands Jacksonville, allowing them to become quickly accustomed to the patient care environment.

“I love UF and I am proud of this program, we have a really great student base,” Motycka says.

The program also gives more students the chance to go to pharmacy school, particularly those who would not have been able to leave their hometowns. Like Hincapie-Castillo, who says it would have been difficult to leave the Jacksonville area, where he has family.

“I have a lot of friends who have families and children and cannot move,” he says. “Having distance campuses is amazing for them. Also because we do projects in the community, it helps to have distance campuses because we can reach more patients.”

Want to know more about UF&Shands in Jacksonville? Visit jax.shands.org/history.