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Dr. Paul John Calricaraq Project Underway in Bethel

Combining culture and innovation for the healthiest people


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YKHC President and CEO Dan Winkelman, far right, and Arcadis Senior Project Manager Kent Crandall listen to an elder in Shageluk, a community northeast of Bethel on the Innoko River. Winkelman and Crandall were participating in the men’s circle at a Cultural Visit last May. Shageluk was one of several communities the YKHC leadership and design team traveled to so they could discuss the project and understand important cultural practices that would inform design.

Photo courtesy of YKHC

The last barge to Bethel up the Kuskokwim River brought pilings and thermocouples for one of the biggest construction projects in Alaska last fall, and the first barge this spring will bring the steel that was ordered in December. The $300-plus million Dr. Paul John Calricaraq Project (PJCP) consists of a new clinic and renovation of the Yukon Kuskokwim Health Corporation (YKHC) hospital and will improve the health of regional residents in innovative and ground-breaking ways. In fact, the entire project, from inception to financing to design and engineering, is innovative and ground breaking. The project itself is named after visionary elder Dr. Paul John.

According to project documents, “YKHC President and CEO Dan Winkelman mandated the inclusive cultural identity and values for the project.”

Winkelman said: “It will be more than just a new building. We are merging Paul John’s inspirational teachings and stories of traditional ways of healthy living with national best practice models to provide healthcare services more efficiently and a customer-centered approach … that incorporates the region’s Yup’ik, Cup’ik, and Athabascan cultures.”

A wide cross-section of people representing YKHC, including Winkelman, the Executive Board, staff, and customers determined the project’s scope and direction in line with the YKHC mission: “Working together to achieve excellent health.”

Chairman of the YKHC Board of Directors Esai Twitchell Jr. says, “The PJCP is a much needed project for our region, as we have outgrown the existing facility and it has limited our ability to provide quality care for our people. This project will have a tremendous impact and will change the way we provide service to our people. “

The project team, including the architectural firms Bettisworth North, ZGF, and Jones & Jones, worked with the YKHC group as well as area residents to develop a cultural design for the project that embodies Calricaraq and thousands of years of Yup’ik, Cup’ik, and Athabascan cultural identity and values.

 

The Paul John Calricaraq Clinic at night.

Rendering courtesy of Bettisworth North

 

Calricaraq

Calricaraq is a concept adopted by Yukon-Kuskokwim elders and the YKHC Preventative Services Department in 2012 and is the guiding principal of the project and its design. According to project documents, Calricaraq is “a foundation based on the belief that there are important teachings and lessons that each person must learn to become strong and healthy … Genuine Yup’ik/Cup’ik teachings, values, and traditions are applied throughout the early child and adulthood developmental stages to live a healthy and balanced life. … To be productive members of a community, knowledge is instilled through healthy parenting, family, and most importantly, by elders who are skilled and knowledgeable in Yup’ik/Cup’ik ways. Collectively, these traditional responsibilities play important roles in emphasizing a healthy people, beginning at conception into adulthood and continuing through eldership.”

YKHC is responsible for the health and wellbeing of some 30,000 Alaska Natives from fifty-eight tribes in more than fifty villages in the Yukon-Kuskokwim Delta and upriver. There are forty-one small village clinics and five larger sub-regional midlevel clinics with a higher level of care that includes lab, diagnostic imaging, and dentists. Community health aides staff the clinics through the Community Health Aide Program, better known as CHAP. In addition to the clinics, YKHC has its flagship regional hospital in Bethel.

Healthcare needs have grown exponentially over the years. In 1990, YKHC had 220 employees with a $6 million yearly payroll with 50,000 annual patient visits. In 2016, there were 1,300 employees with a $75 million yearly payroll with 240,000 annual patient visits. It is anticipated the new facilities will create 200 to 400 new positions.

Demographics for regional Yup’ik and Cup’ik include a high birth rate of 11.257 per capita, with 46 percent of the population under the age of eighteen. YKHC is creating healthcare facilities that will serve the population through the next fifty years based on the concept of Calricaraq with an enduring design.

The Yukon-Kuskokwim region has a high rate of unemployment, which typically fluctuates from 17 percent to 25 percent. The five leading causes of death are cancer, heart disease, unintentional injuries, suicide, and chronic lung disease. Of Alaska’s 4,000 households without proper water and sewer that rely on honey buckets, half are in this region—2,000 homes. Multi-generational households in small houses are typical. The Paul John Calricaraq Project is a journey to high reliability with vivid visioning for the tribes, employees, and patients and their families. The LEAN production system was selected and prioritizes core culture and identity, promoting customer-centered care, and an affordable and sustainable budget.

The new clinic and the hospital renovations are designed to fulfill the YKHC vision: “Through Native self-determination and culturally relevant health systems we strive to be the healthiest people.”

 

The Paul John Calricaraq Project site in Bethel on the Yukon-Kuskokwim Health Corporation campus.

Photo courtesy of YKHC

 

Financing

The ability for YKHC to finance the $300-plus million project was made possible through federal and state legislation and joint venture cooperative agreements.

In 2015, US Senator Lisa Murkowski and US Senator Dan Sullivan sponsored Senate Bill 230 and US Representative Don Young sponsored House Resolution 521, which transferred ownership of the hospital from the Indian Health Service (IHS) to the YKHC. The Alaska delegation’s legislation passed and was signed into law by then President Barack Obama.

Also in 2015, Alaska State Senator Lyman Hoffman sponsored Senate Bill 46 and Alaska State Representative Bob Herron sponsored companion House Bill 101, which authorized regional health organizations access to up to $205 million in low interest bonds through the Alaska Municipal Bond Bank Authority. Both bills passed and were signed into law by Governor Bill Walker. Currently, YKHC is in the process of securing $102.5 million from the Alaska Municipal Bond Bank Authority in long-term financing.

Later in 2015, the US Department of Agriculture Rural Development agency committed $165 million in a low interest loan to YKHC for long-term financing of the project at a fixed interest rate of 3.625 percent. The money will be loaned after construction is complete and is the largest Community Facility loan ever made by the agency for any project in the United States. Former USDA Rural Development Alaska Director Jim Nordlund was instrumental in obtaining the commitment.

In March 2016, a Joint Venture Agreement was signed by YKHC and IHS to provide more staffing to meet the healthcare needs of regional residents. This agreement is expected to more than double the amount of money IHS provides to YKHC for staffing and operations by 2025. As a result of all the legislation and agreements, YKHC is able to expand and renovate its facilities and build new staff housing in Bethel to accommodate the need for increased services.

Short-term financing for construction is being provided by investment house Raymond James.

 

The Project

The project is a renovation of the existing 105,000-square-foot hospital and new construction of a three-story, 175,000-square-foot clinic. A fifty-four unit apartment building will also be built on the YKHC’s twenty-three acre site in Bethel for employee housing. Construction of the clinic began last fall with site work, installing thermocouples, and pile driving. Structural steel erection for the clinic will commence this spring once the first barges bring those materials into Bethel. In addition to Bettisworth North, ZGF, and Jones & Jones, the construction team includes ARCADIS, project manager; CRW Engineering Group, LLC, civil engineer; RSA Engineering, Inc., mechanical and electric; BBFM Engineers, Inc., structural; and JV ASKW/Davis, general contractor. Bethel Services Inc., a subsidiary of Bethel Native Corporation, was selected as the Design-Build contractor for the YKHC Staff Housing, and they are working with architects Livingstone Sloane. The fifty-four unit staff housing complex is expected to be completed in October this year and was required by IHS to support the larger project.

There is a sense of urgency for the big project, and YKHC has been fast-tracking the design, construction, and pile driving in order to finish as soon as possible. They did not want to add another year to the timeline, so last fall they forward-funded the project and spent a few million dollars to bid out the pilings and get them shipped out of Seattle before the last barge. They bought land adjacent to the site to stage construction equipment and materials. They purchased a used man camp built of ATCO trailers to house the construction workers and brought it to the site. Gravel mined upriver is being used for the construction, a logistical advantage for compressing activities that have to take place during the short shipping season.

Pile driving commenced last fall. There is no bedrock in Bethel and the piles were driven fifty-five feet into ice and allowed to freeze back all winter. As for worries about the ice melting, there is no danger in that happening for at least the next fifty years, according to the arctic engineering that went into the project. Thermocouples were installed along with the pilings and will keep an eye on temperature fluctuations.

Structural steel erection is scheduled to begin this spring and be completed by the end of the year. The building enclosure is slated for completion by the end of the first quarter next year. The building interior work is expected to take two years, starting at the beginning of next year with completion expected by the end of 2019 for all three floors. Completion and occupancy of the first two floors of the clinic is expected by the end of June 2019. Hospital renovations will begin mid-year 2019, with completion scheduled by the end of June 2021. The project will meet LEED silver status and IHS sustainability requirements.

Hospital renovations include a partial demolition and total consolidation of outpatient and inpatient services to meet four goals of care. One, it provides a single place for patients and families to go for care. Two, it simplifies patient access with a north inpatient and outpatient portal and a south emergency services portal. Three, with everything together, the integrated Patient Care model is supported for holistic medical, behavioral, and social work treatment. Four, everything reflects and reinforces regional cultural values and traditions and that encourages holistic health and well-being.

The preliminary concept design listed the hospital renovation as a way to “continue to provide inpatient care, including emergency, diagnostic imaging, and surgery; behavioral health clinic decision unit located adjacent to emergency with overnight stay capability; provide logical connections between services; allow for logical renovation phasing and minimize number of relocations during renovation; clear wayfinding routes including link to new clinic building; and enhance patient experience and replace aged building systems.”

The multi-year project will employ hundreds of workers across multiple trades and specialties.

 

Close-up of two piles and a thermocouple at the YKHC project site in November 2016.

Photo by Susan Harrington for ABM

 

Integrating Culture

Winkelman told the entire team, “Integrate culture into the whole project,” and that is what they’ve done, using cultural elements of the four worlds—human, natural, animal, and spirit—throughout the interior and exterior design; layout and flow of rooms and offices; lighting, windows, and doors; placement of art; finishes used on floors, walls, and ceilings; and every other aspect of the buildings and grounds.

The new three-story clinic includes outpatient services on the first two floors and inpatient hospital expansion integration on the third floor. Dental care, rehabilitation services, laboratory, pharmacy, wellness center, patient financial services, and behavioral health will go on the first floor. Half a dozen spaces for primary care, specialty care, and behavioral health are designated for the second floor along with diagnostic imaging, education and group consulting space, and an employee area. Acute care, labor and delivery, surgery C-section, eye care, respiratory therapy, audiology, and infusion are planned for the third floor, which consolidates inpatient and outpatient care.

The entrance to the clinic will be a gathering space and use the qasgiq, or traditional men’s house, as a cultural reference with a traditional roof and ceiling structure. It will include a cultural items display case with the fifty-eight tribes of the region and a craft selling table area on one side and cafeteria dining and table seating area on the other side. Comfortable seating groups with places for children and places for elders will take up part of the space in the center. The gathering space will include a glass screen behind an area for a speaker and stage.

Each floor will have a theme that includes cultural elements for upriver, delta, and the coast from the four worlds, including water (first floor), land (second floor), and air (third floor). Natural light via high windows and translucent walls will be used throughout the clinic. Also, this will not be a museum or a sterile-looking healthcare facility. Artwork will be abundant throughout, with high wall photo panels of intergenerational images, regional landscapes and ancestors, landscape and subsistence, inspiration from creative people, healing power elements, air and birds, animals, fans, masks, drums, and the sea. Many cultural elements from the four worlds will flow throughout—guiding people on a healing journey.

The entire project, from conception to construction is another journey that’s well on its way.

“After getting our company in the black a year prior, partnering with the Indian Health Service to enter into a successful joint venture agreement, working with the Legislature to allow tribal health organizations access to Alaska’s Municipal Bond Bank and then Congress to transfer ownership of the hospital from the IHS to YKHC, I and my senior leaders then assembled a team of about fifty to work on the project itself,” Winkelman says. “Everyone’s enthusiasm for the project was overwhelming. We worked on project management, population and economic forecasting, architecture, engineering, and public and private financing. Everyone came to the realization that, like our customers, this project was special and would greatly improve the lives of the thirty thousand people in the YK Delta for the next fifty years! To be a small part of that team is a dream come true. After all, it’s not every day you get to build a new hospital and increase its staffing.”

 

Susan Harrington is the Alaska Business Monthly Managing Editor.

 

This article first appeared in the March 2017 print edition of Alaska Business Monthly.

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