IRVINE, CA-Unlike other commercial real estate asset classes, medical office has a different element: the health systems themselves. Constructing and repositioning medical-office assets successfully requires a deep understanding of what health systems want and need today, and that comes with time and experience, Thomas LeBeau, CEO of Accretive Realty Investment LLC, tells GlobeSt.com.

As GlobeSt.com reported earlier this week, Accretive recently disposed of three repositioned medical-office assets in Aliso Viejo and San Clemente to a private-equity fund. One of them, Oceanview Medical Center, was 80% leased when Accretive purchased it. These dispositions beg the question of what a successful medical-office repositioning requires and entails.

"We've been at this since we started the company in 2002 to respond to the earthquake retrofit bill," LeBeau tells GlobeSt.com. "We'd been anticipating this market for quite some time. Our expertise among our competitor peer group is delivering buildings either from the ground up or value-add in the 20,000- to 60,000-square-foot range."

LeBeau says that the type of repositioning his firm is doing is filling a demand in the healthcare industry itself, in which there is considerable consolidation going on, as GlobeSt.com has previously reported. Transwestern also reports that the Affordable Care Act is responsible for a paradigm shift in the way healthcare services are delivered and the places people go to receive treatment as acute care moves away from the hospital setting and out into the community.

 "Health systems are acquiring individual physicians and healthcare facilities to leverage off a uniform infrastructure rather than a multi-tenant medical-office building in which there a lot of different-sized practices from as low as 1,000 square feet to as high as 35,000 square feet," says LeBeau. "Those practices and physicians are now joining larger practices and multispecialty practice units, and their space demands are increasing."

Many of these consolidated practices share a reception area and patient rooms, so the health systems they belong to are looking to create larger floorplates to accommodate them. For example, the firm moved two tenants within Oceanview Medical Center and was able to open up an entire floor to accommodate MemorialCare Health Foundation, which has an affiliated hospital across the street.

In addition to common-area upgrades, some of the renovation changes necessary for older medical office buildings include making the building feel less clinical and more patient-focused. This is done by adding wood and removing metal, restructuring the office to allow better patient flow and providing clear, contiguous square footage to allow patients to be seen and treated quickly, says LeBeau. "We look at the existing building and the tenancy and see if we can deliver the larger chunks of space that are going to be required in some submarkets, and then we ask if we can redesign the common areas of the building to bring them up to the standard being delivered on the floor that we're renovating."

Sometimes, an MOB won't meet Accretive's criteria for repositioning, particularly if the elevator goes through the center of the building, preventing large blocks of contiguous space. "To be successful in healthcare today, it's less about being a real estate expert and far more about being knowledgeable about healthcare, healthcare delivery and patients," says LeBeau. "To do what we do, you have to understand what your client is trying to accomplish. 'Can I get the utility out of the building that the health system needs, and how badly does the health system need to be in that market?' It takes a certain set of skills that are not readily available over the counter. You need to have great medical-specific property managers and brokers. We've assembled the right team of specialists to deliver what the market demands."