Less Is More: Independent Clinics Find Niche In North Dakota

MINOT, N.D. (AP) — A desire to give patients a more personal style of health care and sometimes a broader range of services has led to a growing number of independent clinics operated by mid-level providers in the Minot region.

In recent years, Minot has gained several clinics operated by nurse practitioners looking for autonomy and a way to better deliver the type of care that patients indicate they want.

“One of the major factors in opening Legacy Health Clinic was the lack of health clinics that really took the time to listen and understand their patients. We know how hard it can be to find a provider and health clinic that you can trust and feel comfortable in, so we became that place,” said owner and nurse practitioner Cim Berg-Hooker. “I think patients choose Legacy Health Clinic as the best option for their care because it doesn’t feel like your traditional office visit. From the moment you walk in, you’re greeted with a warm smile. Each of our patients leaves feeling great.”

In North Dakota, nurse practitioners do not need collaborating physicians to oversee their practices. North Dakota is among states where nurse practitioners and physician assistants can be in private practice. They can refer to specialists and typically do so based on patient preferences and insurance networks, the Minot Daily News reported.

Legacy Health Clinic is Minot’s newest clinic, having opened its doors last August. A coffee bar with snacks and the clinic’s modern decor create a non-clinical feel to help ease the jitters of a medical visit.

Legacy provides traditional health services and is the first health clinic in Minot to offer IV therapy.

IV therapy is a hydration treatment that offers a selection of nutrition, vitamin or medicinal products that are delivered intravenously to help with conditions ranging from bloating to migraines or chronic pain. It also has been used in post-COVID recovery.

Legacy attracts patients from across the state because it is one of few clinics specializing in medical marijuana. Berg-Hooker received instruction through the state Division of Medical Marijuana and follows state prescribing rules, which specify conditions for which people are eligible for a prescription. Patients take their prescriptions to a medical marijuana pharmacy to receive the appropriate product. However, Berg-Hooker continues to follow up regularly with patients as required by the state.

The clinic is expanding its services into women’s health and mental health, Berg-Hooker said.

“We are big believers in continuing education so we are always expanding our areas of expertise. Our major priority is our patients’ health, so the more we learn the better we can serve them,” she said. “We are currently looking for another provider to join our team, and we have two providers that are joining within the next two months.”

Berg-Hooker, who worked as a nurse before becoming a nurse practitioner, has been employed in a variety of medical settings. She still does some work in Watford City as a traveling practitioner.

Her family members are a part of her clinic business, helping with marketing, social media and technology. She said she considers her decision to start her own practice to have been positive, both for herself and for patients.

Susan Collins, who opened Triple C Clinic last April, said she has no regrets.

“This was my goal in life, and I am so happy to be here,” she said.

The primary-care clinic currently is geared toward walk-in patients.

“There’s no waiting,” Collins said. “If they call, they can just come in and I’ll see them. They like that there’s no waiting.”

Collins has served the medical needs in her hometown for many years. From paramedic to registered nurse to nurse practitioner, she has taken different roles. She left Sanford Health’s walk-in clinic in Minot to open Triple C.

Having her own clinic enables her to focus on her patients and stay on top of their care, Collins said.

Independent practice isn’t for everyone, though, she added. Starting a practice comes with considerable up-front costs and there are hoops to jump through with registering a new business and credentialing the business with insurance companies.

Collins, who has a degree in business, said she knew what she was getting into, but it still has been challenging with the startup details and the ongoing billing processes.

Trisha Fennern, owner of Minot Health Clinic, agrees that the business end of a clinic consumes time that she might rather spend on patient care, which is a trade-off in operating one’s own clinic.

Fennern, who left Trinity Health to open Minot’s first nurse practitioner-operated, primary-care clinic seven and a half years ago, said she just had a sense that she wanted to go out on her own and doors opened to make it happen. She said she appreciates having the ability to spend as much time as needed with patients and help them in ways she otherwise would not be able to, while operating under the motto of “professional care with a personal touch.”

“My goal for my staff and providers and for myself is just having a place where patients can come and discuss their concerns, because I have a lot of patients who are quite reserved and just kind of scared to tell us what all their concerns are because they feel like they’re not validated. I just want patients to know that no matter what kind of concerns that you have, it’s never too much for us to try to sort out,” Fennern said.

Minot Health Clinic’s approach has an appeal, as indicated by the majority of patient traffic generated by word of mouth from other patients.

“It’s the experience that they get. It’s the result that they get. It’s the personalized care and attention that we try to give our patients,” Fennern said. “When you see them get better after years and years of struggling, it just makes a difference and it makes us want to keep doing what we’re doing.”

Minot Health Clinic offers some aesthetic services for cosmetic purposes, but the heart of the clinic’s work is its hormone evaluation treatment, emphasis on gut health and micronutrient testing.

“We do a lot more functional medicine, which again tries to get to the root of the issue,” said Fennern, who has two other nurse practitioners on staff and a third coming in February. Brittany Haugtvedt started as a nurse at the clinic before advancing her credentials to nurse practitioner. Sandy Storey also worked as a nurse for many years before becoming a nurse practitioner and later joining the clinic. The clinic re-located to a larger space in August 2020.

LOOK Aesthetic Atelier opened in the summer of 2018, moving downtown in 2019.

Owner Kelly Dickinson said she had been a nurse looking for a part-time job when a position came up in a Minot aesthetics clinic. She said she fell in love with the work, so after attaining her nurse practitioner credential, she acquired a practice from its owner who was moving out of state.

“It is a very fun field. When you’re talking about the medical field or the field of nursing, you get into it to help people. And this is just a different way of doing that. You’re helping their confidence, their self esteem, mental health,” Dickinson said.

Under state law, the aesthetic procedures performed by the clinic require a medically trained practitioner. Dickinson said the training is important because the work involves medications, injections and an understanding of contradictive health conditions as well as human anatomy. It is also important to clients to know that their providers are knowledgeable, she said.

Because aesthetics wasn’t part of her nursing education, Dickinson has gone on to attain considerable additional training. Continuing education also is part of her profession.

LOOK Aesthetic Atelier’s most popular offerings are Dysport injections and laser hair removal. Dysport addresses wrinkles through relaxing muscles in the face.

“It’s growing exponentially everywhere around the country,” Dickinson said of the treatment, which has drawn clients from across western North Dakota, eastern Montana and Canada.

In addition to Dickinson, the clinic has two part-time nurse practitioners, Ashley Wallner and Andrea Sebelius. The clinic also has an esthetician who provides facials that promote skin health.

Dickinson said the ability to work in a laid-back atmosphere with flexible scheduling is among the best parts of her job. It is not where she would have pictured herself 15 years ago as a nursing student, she said, but she’s been surprised by people from all walks of time, both men and women, who have become clients of LOOK Aesthetic Atelier. Like coloring one’s hair or buying a new outfit, aesthetic services are another way to feel good about yourself, she said.

“Whatever makes you feel the best. And this is just what we do and what we can do for you,” she said.

Although more rare across the state, physician assistants have opened their own clinics as well. Only since 2019 have they been able in North Dakota to practice independently without a supervising physician on site.

In Kenmare, Shelley Bartow opened Compass Health this past summer.

“We’ve had a great response. I think people, for the most part, they kind of like the small business owners,” she said. “When they call and they ask to speak to me, they actually get to speak to me.”

Patients appreciate her commitment to the community, she added.

“I’ve been in the area since 2004. I’m not going anywhere, and people appreciate that familiarity — knowing who they’re going to see,” she said.

Originally from the Bismarck area, Bartow graduated as a physician assistant from the University of South Dakota in 2003. She took a job with St. Luke’s Hospital in Crosby, working at clinics in Lignite, Bowbells and Crosby with the idea that she would move in a few years. Instead, she settled in and worked for St. Luke’s for about eight years before joining Northland Health Centers in 2012.

Last spring, she and another physician’s assistant with Northland decided to partner in operating clinics in Kenmare and Ray. Because independent physician assistant practices were a novelty, it took time to persuade the N.D. Board of Medicine to approve the proposed clinics.

“They had a lot of concerns, which are legitimate concerns,” Bartow said. “We’re not physicians. We don’t pretend to be physicians. We still need that physician backup.”

Bartow collaborates with a Mandan physician in her practice. She and her partner determined early on that separate practices would be a better option for them, and Bartow worked with the Kenmare Development Corp. to remodel and equip a building for a clinic in that community.

That was during the height of the COVID-19 pandemic, when Bartow also was working as medical officer for the North Dakota Army National Guard. Consequently, the clinic didn’t open until last June.

It can be overwhelming to see patients and still manage the business side with just a receptionist, but Bartow hopes to eventually add more staff. Compass Health provides primary care services and looks to add adult vaccinations. The clinic partners with the Kenmare hospital for testing services.

Bartow specializes in women’s health care and hormone testing, working with a compounding pharmacy in Dickinson on specialty medications. The clinic has contracted with a mental health provider who comes to Kenmare once or twice a week.

Bartow said she can offer more comprehensive care because she is not having to work within the limits set by an employer.

“I can practice medicine the way I feel it should be practiced,” Bartow said. “I know these patients, and I know some patients need more time than others. So I can spend more time with the patients that need more time. I don’t feel as rushed.”

She also likes the flexibility of being self employed. She can support her daughters’ activities without worrying about getting time off.

Minot’s independent nurse practitioners say more clinics like theirs can be expected to spring up, but Bartow said physician assistant practices aren’t likely to increase significantly. State rules have tightened even since her practice opened, she said. Future clinics need to be located in rural areas identified as health professional shortage areas, which largely entails communities smaller than Kenmare.

“That’s why the PA profession was created was to fill this niche, was to be a physician extender — to be in the areas where physicians couldn’t be,” she said. “Physicians aren’t coming to Kenmare, North Dakota. We’re trying to fill that gap in healthcare.”