Rendina Companies share their knowledge on the essential keys to the successful development of medical real estate

As in all fields of real estate, commercial real estate is cyclical. But not all areas in the real estate market are directly related to the economic climate. There exist a few areas in commercial real estate that, for the most part, maintain stability and are not heavily impacted by the economic climate. One such industry is medical real estate development, which primarily encompasses the planning, construction and management of medical office buildings. Certain characteristics inherently found in the planning and management of well executed medical real estate development projects include the recruitment of creditworthy tenants, securing triple net leases, the procurement of long-term leases, structuring the lease contracts to include annual escalations in the base rental rate and offering tenants shared ownership in the partnership structure that owns the facility.

Creditworthy tenants

Creditworthy tenants are always integral in stabilizing any commercial building, particularly a medical office building. What makes medical real estate development a viable field is that it attracts financially viable tenants who are stable and willing to commit to long-term leases. It’s the nature of the tenants that make it a good business.

Triple net leases

A triple net lease is an effective way of leasing commercial space. This type of lease requires that all utilities and operating expenses of the building are passthroughs to the tenants. Everything from taxes and maintenance to security and insurance premiums are included in the operating expenses allocated to the tenants. A triple net lease essentially obligates the tenant to assume responsibility for the leased premises. In this type of lease the rental component is noted separately, allowing the owners to easily identify their net investment return.

Long-term leases, annual rent escalations

It is standard practice in the leasing of medical office space for physicians to sign long-term leases. Leases with annual rent escalations are also a standard part of commercial leasing contracts. In order to ensure a positive cash flow in a building, there must be annual escalations in the rent of a project. Long-term leases are a key element to the financing of and stabilization of a project.

Shared ownership

One of the unique opportunities Rendina Companies offers to the tenants of its projects is ownership in the partnership structure that owns the facility. This benefit is provided in return for the long-term lease commitment and personal guarantee on the part of physician tenants. As equity partners, the tenants share in the net operating cash flow and equity appreciation of the project.

Today, more and more healthcare systems are looking to medical real estate development firms to construct, finance, lease, own and manage medical office buildings on and off their campuses. Historically, hospitals built and owned their medical office buildings and, in many cases, have subsidized leases in order to attract physicians to their campus.

Due to a hospital’s complexity and cost accounting systems, it is almost impossible to fully accrue all of the expenses incurred by a medical office building. It is also seemingly less of a priority for the hospital to focus their attention on their medical office buildings. Hospitals generally lack the property management skills needed to maintain a medical office building, eroding the value of the asset. In addition, as hospital reserves continue to deplete due to reductions in reimbursement and rising operating costs, hospitals have been exiting the medical office building management business and have been selling off medical office buildings to monetize their assets and allocate money into their core business of patient care.

Medical real estate developers work with hospitals and physicians to accommodate their needs while providing quality and state-of-the-art healthcare facilities to the community. Historically, medical office buildings were not designed well enough to adapt to the rapidly growing healthcare industry. Today, however, we are seeing more and more medical office buildings that are meeting and exceeding the needs of physicians and their patients. The future of medical real estate development is bright, with more and more physicians seeking facilities that meet their needs and house fellow practitioners. This physician demand – along with the consolidation we are seeing on hospital campuses – is a driving force behind this type of medical development. In the coming years patients should expect to see many of the outpatient services presently being provided by hospitals to be offered by specialists in the comfort of their own fully outfitted and customized medical office suites.



The Martin Memorial Public Relations and Marketing department recently received several Image Awards at the annual awards luncheon. The Image Awards are hosted by the Treasure Coast Chapter of the Florida Public Relations Association and recognize top public relations professionals and programs in the area.

The Martin Memorial employee newsletter, Access Martin, and the electronic consumer newsletter, Health E-news, both received Judges Awards. This award is presented to those entries that achieved maximum results while using a minimum amount of money.

Along with the Judges Award, Access Martin also received an Award of Distinction, which is given to an entry that achieves a set standard of excellence.

Top-scoring entries in each category within a division were awarded Image Awards. The Martin Memorial Web site, www.mmhs.com, was given an Image Award in the audio-visual tools division. It was also awarded a Grand Image Award, which is presented to the top entry in that division



National Hospice Month is acknowledged and celebrated every November by hospitals, nursing homes, adult living facilities, administrators, doctors, nurses, nurses’ aides and of course hospice providers and programs. Like Social Workers’ Month and Long Term Care Week, it spotlights a population of clinicians and caregivers who otherwise perform extraordinary jobs without fanfare.

At VITAS Innovative Hospice Care® programs in Miami-Dade, Broward and West Palm Beach this month, you’ll find posters on the walls and buttons extolling the efforts of hospice caregivers proudly worn by team members: “Patients and Families Come First.”

But what we also do at VITAS, every day of the year, is advance the body of knowledge on hospice. Who is hospice-appropriate? How do you manage pain, or measure quality, or care for skin ulcers, when caring for the terminally ill? What are the ethical considerations in artificial hydration and nutrition? Why are some clinicians so ill-prepared to deal with death?

For the past 25 years VITAS has been asking and answering those questions and many more in our continuing effort to “Do Our Best Today and Do Even Better Tomorrow.” Finally, in 2002, we put it all down on paper and literally “wrote the book” on hospice. 20 Common Problems in End-of-Life Care is a 450-page book in 20 chapters that walks the clinician through the perceived complexities of providing patients and families with quality end-of-life care. Nineteen respected and authoritative VITAS professionals—from physicians and nurses to social workers and chaplains—contributed their expertise to produce this text. It is appropriate for any physician, regardless of level of training or specialty, who sees end-of-life care issues in her or his daily practice.

I knew this book needed to be written. I knew it because of the questions I have fielded in my 21 years in hospice care as a team physician, South Florida medical director, national medical director and chief medical officer. I knew it based on the disconnect between theory and practice that I have seen and heard in audiences as I speak about hospice and palliative care all over the country. However, what most convinced me to write the book on hospice was a passage in Harrison’s Principles of Internal Medicine, arguably the bible of internal medicine:

No problem is more distressing than that presented by the patient with an incurable disease, particularly when premature death is inevitable. . . . The physician also must be prepared to deal with guilt feelings on the part of the family when a member becomes gravely or hopelessly ill.

When the major text of internal medicine says I am supposed to be distressed when I am confronted with a patient with a terminal illness, how am I supposed to help the patient deal with his or her distress? When the terminally ill are equated with the hopelessly ill, how can I give hope to my patients at the end of life—when I’ve already been taught that they are hopeless?

The goal in writing 20 Common Problems was to diminish or even erase the distress physicians feel when faced with a patient’s terminal illness, so that physicians are better equipped to help those patients and their families at the end of life. With my associates and co-editors, Dr. Neal Weinreb and Dr. Joel Policzer, I attempted to make the book a “who, what, where” of care at the end of life: to teach physicians to recognize when a patient needs end-of-life care, to work with the patient and the hospice team, to know they’ve made a good decision and to understand the care being given.

End-of-life care is unlike anything else taught in medical school. In fact, it is still not taught in most medical schools. But when a physician understands it, even feels a part of the hospice team, the result is a realization that it is not “doing everything” that makes the difference at the end of life. It is the simple and methodical application of sound hospice practices and extraordinary human kindness administered day by day, one on one, without fanfare. And that is what we celebrate, every day at VITAS and every November in the rest of the world.

To request a copy of 20 Common Problems in End-of-Life Care, call (561) 364-1479 in West Palm Beach, (954) 486-4085 in Broward or (954) 437-5433 in Miami-Dade.



The New Broward General Medical Center was the setting for the dedication gala for the Heart Center of Excellence.

Current and former Commissioners of the North Broward Hospital District gather with administrators for the ribbon cutting.

1st Row l-r: Daniel E. Gordon, Rebecca L. Stoll, Gul Cumber, Paul Sallarulo, Ana Gardner
2nd Row l-r: Robert C. Bernstein, North Broward Hospital District President/CEO Wil Trower, Michael Moskowitz, J.Luis Rodriguez and Broward General Medical Center CEO Joe Scott
3rd Row: Steven Berrard

The event honored the generous donors who supported the expansion and renovation of The Heart Center of Excellence, a world-class facility dedicated to the fight against heart disease which is the nation’s number one killer.

“The Heart Center of Excellence sets the standard,” said Dr. Michael Chizner, Chief Medical Director of the Heart Center of Excellence. “It is where state of the art technology and compassion come together with research and education allowing us to provide the finest heart care possible to those we are privileged to serve.”

In addition to the new Heart Center of Excellence, Broward General’s recent expansion included the construction of a new emergency department, trauma center, outpatient surgery area, intensive care units, surgical suites, and parking garage.



The Barry University School of Nursing addresses the national shortage of nurses by preparing nurse educators

For two years, Carol Savanello says, she prayed that nothing would happen to her mother. That’s how long it took the registered nurse to earn her bachelor’s degree in nursing through the RN to BSN program at Barry University – and she wanted to share her accomplishment with her mother by having her mother pin her at the traditional ceremony that serves as a rite of passage for nurses. “This was between me and mom,” Savanello explains. A graduate of a nursing diploma program in Chattanooga, Tennessee in 1949, Jean Ragan inspired her daughter to become a nurse too. After serving as a labor and delivery nurse for 25 years, first at North Shore Medical Center then at Baptist Hospital, Savanello decided to pursue the bachelor’s degree her mother never had. “She also wanted to go back to school, but with kids, she never did,” says Savanello. Last May, the 46-year-old college graduate watched Ragan lean on her cane as classmates and professors helped her mother cross the stage to pin her. She remembered what her mother had always told her: You’re never too old to learn.

Jean Ragan (mother) and Carol Savanello

Savanello and her mother share an experience common among nurses. “Nursing is still mainly a women’s profession,” observes Dr. Sandra Walsh, a faculty member in the doctoral program at Barry’s School of Nursing. “A lot of women go back to school later in life because they’re balancing their careers and their families.” Walsh earned her bachelor’s in nursing from Duke University in 1960, but did not pursue her master’s and doctorate until nearly 30 years later, when she was 50 years old. Now 68, the professor sees her role as preparing the next generation of nursing educators. She is only half joking when she says, “I’m just trying to hang on long enough to get people to replace me.”

Dr Pegge Bell (left), Dean of BU’s School of Nursing, and Kim Greene, Executive Director of John T. Macdonald Foundation

Like so many nursing faculty across the country, Dr. Walsh is talented, dedicated, and almost ready to retire. The median age of nursing faculty at all ranks is 48.8 years. “Within the next 10 years, many of the current faculty are expected to retire,” says Dr. Pegge Bell, dean of the Barry University School of Nursing. “Yet the pipeline of new nursing faculty is small.” A shortage of faculty contributes to the shortage of nurses nationwide. The American Hospital Association reported recently that more than 32,000 qualified applicants were denied admission to nursing schools, primarily because there were not enough professors to teach them. There are currently more than 600 open faculty positions at U.S. nursing schools – a vacancy rate of about 8.6 percent. Determined to change that, Dean Bell says, “At Barry, we have targeted our scholarships and grants towards producing nursing faculty for the future.”

Dr Jesse Collin

Grants to the University from the John T. MacDonald Foundation, the North Dade Medical Foundation, and Blue Cross and Blue Shield of Florida – The Community Foundation further the mission to educate future leaders. Barry also is one of three nursing schools that received a SUCCEED grant from the Florida Department of Education to fund a pipeline for students from associate and baccalaureate degree programs into graduate programs and to encourage students to become tomorrow’s faculty. The SUCCEED grant helps get the word out that faculty salaries are now more competitive with hospital salaries, with flexible schedules that leave time to publish articles, conduct research, and attend professional conferences.

Promoting doctoral study does more than fill vacant teaching positions. Dr. Walsh, who won the highest honors for teaching excellence at Barry University this year, encourages her students to think of themselves not only as teachers, but as scientists. “Doctoral students are generating a new body of scientific knowledge,” she says. “We’re looking at how to take care of people from the broadest of viewpoints and to help people promote their own health.”

Dr Sandra Walsh

Scientific research has direct applications for nursing practice, according to Dr. Jessie Colin a member of Barry’s doctoral faculty as well as an appointee to the Florida Board of Nursing and a cofounder of the Haitian Health Foundation. By conducting research on issues such as women and HIV, depression, and health advocacy, her students help find better ways to provide care. “The way to make the practice better,” says Colin, “is through research.” As scientists and teachers sharing research with their students, nursing faculty will set the course for the future of the profession.