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IMAG INECaring for Our Young Patients

If you ask a colleague in any position across the entire Dartmouth-Hitchcock system why they are here, I expect at their very core, all would answer: the patient. Knowing the wisdom and professionalism every colleague brings to our patients and their families is awe-inspiring for me, and at the very root of creating a sustainable health system.

Recently, I was privileged to chair a committee for the National Academy of Medicine (NAM) to address health inequity in our country. Realizing the preponderance of inequities that exist in our nation only serves to reinforce the commitment we have to create a sustainable health system. We as a nation have much work to do, and the role of Dartmouth-Hitchcock cannot be overstated. New Hampshire and Vermont are not immune to issues of inequity. Economic status, rural isolation, race, ethnicity, access to transportation, health care and education, are all factors we must address if we are to achieve true health equity for our region and our nation. Our work both inside and outside our traditional care models are essential.

In this issue of Imagine, we present some images of the sustainable health system at work, all part of the health equity equation and all related to our expanded “why”— why we are here is to serve our patients and the communities in which they live. What I hope will become clear as you read these stories is that the work we’re doing reaches beyond our clinical facilities. To achieve health for our communities—not just to deliver health care—we need to engage with people where they live, in new and different ways, and with a broad range of partners. We need to reach our neighbors before they need the services of an academic health system, with programs and resources that allow them to manage their health and chronic health conditions.

Some examples of this work follow; you’ll read about our Community Health Coaches; our care management programs through Benevera Health; an exciting outreach program for breast cancer patients championed by Dr. Roshani Patel in Manchester; workshops offered in community settings; and work across New England to provide care to mothers suffering from addiction and their newborn babies.

Our commitment to our communities has never been stronger. The work described in this issue of Imagine is vital to reaching all our neighbors to ensure—as I wrote in the preface of our NAM report—that all our neighbors can enjoy the promise of our Founding Fathers to: “’Life, Liberty, and the pursuit of Happiness’, undeterred by poor health.”

Thank you.

Dr. James N. Weinstein CEO and President

Dr. James N. Weinstein, CEO and President, with a group of Child Life Specialists at CHaD, the Children's Hospital at Dartmouth. Read more about their work in the story starting on page 10.

“Life, Liberty, and the pursuit of Happiness” Declaration of Independence July 4, 1776

in this issue

02 Our Patients | Their Stories Nicola Felicetti shares her patient experience story.

04 Standing Up to Cancer Working to improve breast cancer outcomes through exercise, nutrition and community.

10 Child Life Specialists:Taking Care of D-H’s Youngest Patients Child life specialists help parents and children navigate their care.

14 Living with Chronic Health Issues Self-management programs help patients live a healthy life.

18 A Small Piece in the Puzzle of ALS Scientific research points to algal blooms as a possible risk factor.

22 A Shared Value Inspires a Gift to the Jack Byrne Center

24 Snapshots in Giving

EditorsAnne ClemensVictoria McCandless

Designer David Jenne

Photographer Mark Washburn

WritersBonnie BarberJennifer DurginKaren Kaliski

Published by Dartmouth-Hitchcock Communications and MarketingOne Medical Center DriveLebanon, NH 03756dartmouth-hitchcock.orgAll contents © 2017.

In this edition of Imagine, each of the feature stories highlights one of the components of our vision: creating a sustainable health system, population health management, providing value-based care and establishing new payment models.

On the cover: Pediatric nurse Ashley Ross, RN, evaluates Walker, a young patient.

On this page: A child life specialist escorts twins Elyse and Addyson to their next appointment.

our patients

their stories

All of this has helped me to understand the experience our patients have every day. And, in the end, it has helped me to do my job better.” ~ Nicola Felicetti

2

One early morning in March 2016, Nicola Felicetti, was on a run with her dog, Ollie, when she slipped on hidden ice. “My leg went one way and my foot the other,” Felicetti says. A registered nurse for 30 years, she knew she had a serious injury. “Here I was, stuck in the woods at 7 am in 7-degree weather. Luckily, I had cell phone service. I called my husband, Cal. While he called 911, he told my daughter, Charlotte, where to find me. Charlotte was the first to reach me down near the river in a precarious spot.”

Felicetti was taken by ambulance to Dart-mouth-Hitchcock Medical Center’s (DHMC’s) Emergency Department. “When they showed me my X-rays I couldn’t imagine I would ever run again. I had broken the tibia and fibula in my right leg,” she says. Her leg was put in a cast from her toes to her thigh.

A few days later, Felicetti saw Orthopaedist Marcus Coe, MD, and together they decided that surgery, using a titanium rod and screws to hold the bones together, would be the best option.

The morning of her surgery, her husband dropped her off at the entrance where volunteer, Ed Condict, greeted her and held her hand until her husband came back from parking the car. From that moment, through the rest of her stay at the hospital, Felicetti was very appreciative of the little things the nurses and others did to make her feel comfortable. “I’d never had an IV and I’d never used a bed-pan. These were things I’ve done for patients thousands of times, but to be on the receiving end was so different.” As a nurse at DHMC for the past 13 years, many of the nurses taking care of her knew her. “I felt so honored when they would ask, ‘Do you mind if I take care of you?’”

A few weeks later, Felicetti started six months of rehabilitation with Physical Therapist Steve Vincente. While Felicetti was anxious to put weight on her leg and walk, Vincente was able to hold her back so she wouldn’t reinjure her leg, but also able to encourage her when she needed it. “Thanks to Steve knowing when to hold me back, I can now run again,” she says.

“All of this helped me to understand the experience our patients have every day. And, in the end, it has helped me to do my job better.”

NICOLA

3

STANDING UP

4

POPULATION HEALTH

Roshani Patel, MD, FACS, takes a multi-fac-eted approach to caring for her breast cancer patients by adding exercise and nutrition to the recovery plan.

Improving Breast Cancer Outcomes through Exercise, Nutrition and Community

As excited as Potoula Rakis-Lambroulis

was to learn karate, her first class was

difficult. She couldn’t kick the bag and

catching a weighted ball in a crouched

position felt awkward at best. Now, just

five weeks into class, both moves are

“no problem.” That’s a real achievement.

Rakis-Lambroulis is recovering from

breast cancer surgery and chemotherapy.

STANDING UP TO CANCER

Continued on page 7

5 POPULATION HEALTH

Every week, clinical dietitians from Elliot Health System and Hannaford Supermarkets conduct grocery store tours for shoppers in need of nutri-tional advice. It’s a valuable commu-nity service that Roshani Patel, MD, FACS, has tapped for patients in the Dartmouth-Hitchcock (D-H) Man-chester Breast Cancer Program.

“Dr. Patel is very concerned with dietary intake of high-carbohydrate foods, so we make sure that patients understand how to manage portion sizes and swap out foods that contain too many carbs,” says Marilyn Mills, MS, LD, RD, CDE, senior clinical dieti-tian. “Patients who take the tour learn

how they can significantly improve their diets without completely giving up their favorite foods.”

Besides teaching patients how to swap spaghetti squash for pasta or replace sugar with alternative sweeteners, Mills and other Hannaford super-market dietitians walk them through, literally, the Hannaford Supermarkets’ Guiding Stars® Program. “Guiding Stars is a nutrition navigation system with over 100,000 foods rated with one star for good, two for better and three for best nutritional quality,” says Mills. “No stars, that’s an item we don‘t want to eat daily. During the tour, we read labels, and even visit the meat and

produce departments to learn how to combine foods for easy-to-prepare affordable meals and snacks.”

“I saw a proverb that says, ‘If you’re not eating well and taking care of yourself, you’re wasting your doctor’s time,’” says Potoula Rakis-Lambroulis, a cancer patient who has taken advan-tage of the Hannaford tour. “I always thought I was a good eater, but we don’t realize how much junk we eat, even when we’re trying. I really liked the tours and learning how to use the Stars system.”

Tours take about 11/2 hours and focus on portion control, food swaps and recipes that limit carbohydrates and sugar, and label reading. On-site dieti-tians are available to answer questions and even check through shopping carts to offer advice.

Breast Cancer Program Leverages Community Nutrition Resources

Marlilyn Mills, MS, LD, RD, CDE, senior clinical dietitian for Hannaford's Guiding Stars Program, far left, provides nutritional information to Roshani Patel, MD, FACS, second from left, with some of her patients.

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Technology doesn’t take us away from being doctors, and it makes a big difference.”

~ Roshani Patel, MD, FACS

Rakis-Lambroulis’ karate classes are one part of the Dartmouth-Hitchcock (D-H) Breast Cancer Program’s strategy to close gaps in cancer care delivery, improve patients’ overall health and reduce the risk of reoccurrence. Roshani Patel, MD, FACS, began building the program six years ago along with her team, which includes Todd Noce, DO, Radiology; Steven Birmbaum, MD, Radiology; Steven Kammann, MD, Radiology; Carol Walsh, MS, LGC, Medical Genetics; and Josh Rifkind, MD, Medical Oncology.

“Our first goal as a team is to make sure that cancers aren’t missed,” Patel says. “Dr. Noce and I streamlined our radiology workups, which we now do here at D-H Manchester rather than sending pa-tients off-site. Our radiologists always go through the imaging with patients. It’s an old school approach. Technology doesn’t take us away from being doctors, and it makes a big difference,” she says.

Cancer care, however, goes beyond diagnosis, surgery and treatment. When extensive surgery is required under the arm, radiation and chemotherapy can exacerbate lymphedema (arm swelling). Obesity can make lymphedema even worse. Post-surgical scarring and pain affect range of motion. Some medications cause joint and muscle pain. And chemo-therapy can cause neuropathy.

“Research shows that early intervention and strength training can decrease lymph-edema by 50 percent,” says Patel. “Exercise reduces the chance of cancer reoccurrence by 34-50 percent. We’re invested in out-comes. We want to give patients exercise and nutrition tools that can help improve their survival and decrease disease.”

Top photo: Estela Werner, participates in a karate class.

Bottom photo: Roshani Patel, MD, center, confers with a colleague and Werner, right.

POPULATION HEALTH 7

Martial arts expert, Richard Mullen, teaches karate movements to help with cancer recovery.

ADDING EXERCISE AND NUTRITION TO THE RECOVERY PLAN

Patel looked for local exercise programs that recognized her patients’ needs and challenges. Finding none, she created her own. Patients started getting in shape. Some were even able to be taken off blood pressure medications, medica-tion for Parkinson’s disease and choles-terol medications, and to taper diabetes medications.

Eventually, Mary Ann Aldrich, RN, MS, clinical director for Community Care, at D-H, connected Patel to the YMCA Board of Trustees in Manchester, New Hampshire, which led to the develop-ment of a 12-week LIVESTRONG exercise program for all cancer patients in the Manchester area. Twelve patients allowed Patel to use their medical records to show how exercise led to health improvements in a grant application that secured an

initial $50,000 from Anthem Blue Cross and Blue Shield of New Hampshire. More than 300 patients have already benefitted from the Live Strong program.

Rakis-Lambroulis is one of them. “After chemo, my body was in shock,” Rakis-Lambroulis says. “The YMCA program gave me a kick-start. On top of the exercise, I found a lot of camara-derie and made good friends. Cancer is hard on your self-esteem. Going to the Y, knowing I’d be with other people like me, was a boost. I felt a lot better.”

Cancer recovery takes more than 12 weeks, though, and Patel was looking for other exercise opportunities to offer patients. She found one through Richard Mullen, a patient’s fiancé. “I went to every one of my fiancée’s

doctor’s appointments and chemo-therapy sessions,” says Mullen, who owns and operates American Dragon Karate, in Hooksett, New Hampshire. “I didn’t know anything about cancer, but learned about neuropathy and lymph-edema and thought, ‘We can fix some of that through karate movements.’”

“Mr. Mullen has spent so much time learning about cancer recovery and the muscles involved,” says Patel. “I’ve sent him information and see him using it in classes, some of which I have attended with my patients. It’s been an amazing collaboration.”

Weekly classes are typically attended by patients who are six to eight weeks out from surgery, though some patients

start right after surgery. Patel has seen so much improvement, she has begun send-ing patients pre-surgery. “We understand everyone’s scenario, and make them feel comfortable,” says Mullen. “We do stretching exercises and can add weight to give an extra stretch. Tapping bags with the bottoms of feet or flexing toes and tapping with heels helps neuropathy. I change things up week-to-week so that the class is always interesting.”

Like the LIVESTRONG program, Mullen’s karate classes provide more than exercise. “People can talk to me and each other,” says Mullen. “We like it when participants bring a friend or fam-ily member. One woman brought her whole family. It’s great for our students to do something fun with their kids.”

VALUE-BASED CARE POPULATION HEALTH8

Along with exercise, patients are re-ducing barriers to recovery and the risk of reoccurrence through nutrition. “By balancing proteins, carbohydrates, fats and starch, patients lose weight and balance their metabolism,” says Patel. “I encourage patients to use an app to get a gauge of what they’re eating. I use MyFitnessPal and share my diary so they can see my mistakes—I like my Reese’s Peanut Butter Cups—to make it more relatable.” Patel also accompa-nies patients on nutritionist-led tours of Hannaford Supermarkets (see page 6).

ADDRESSING THE NEED, UNDERSTANDING THE BENEFITS

The D-H Manchester Breast Cancer Program serves hundreds of patients,

but there’s certainly room to grow. “My patients have told me, ‘You’ve done this for us, but we meet so many patients from other hospitals who don’t have these programs,’” says Pa-tel, who would like to secure funding to expand karate classes, which she currently supports on her own.

“We need grants to help fund such programs,” says Patel. “Collaboration with Elliot Hospital, Hannaford’s, the YMCA, American Dragon Karate and other local resources and experts is yielding great results. I’d like to see more of it throughout the state.”

Patel also hopes to better understand why patients who take advantage of exercise and nutrition programs

are doing so well. Recently named the American College of Surgeons State Chair for the Commission on Cancer, she has received interest in research from the University of New Hampshire, and would like to do a retrospective study of her patient outcomes.

“It’s unusual for a surgeon to take a broader view to patient care, but I also have a research background. I have learned that research isn’t any good if it’s not applied,” says Patel. “It’s frus-trating when cancer returns and we wonder if we haven’t given patients all of the tools they need to succeed. It’s great when patients walk in to show me their blood work and say, ‘Look at this! What can I do next?'”

I have learned that research isn’t any good if it’s not applied. It’s frustrating when cancer returns and we wonder if we haven’t given patients all of the tools they need to succeed.”~ Roshani Patel, MD, FACS

9 POPULATION HEALTH

CHILD LIFE SPECIALISTS:

Child life specialist Jeanne "Mollie" Saults, right, accompanies young patient Tristan to surgery.

Child life specialists at the Children's Hospital at Dartmouth-Hitchcock (CHAD) help parents and children navigate their care.

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Taking Care of D-H’s Youngest Patients

Jessica Laperle, child life specialist, admits that her work day is often filled with play time—therapeutic play time. “We might be playing games or blowing on pinwheels, but we’re supporting the developmental, psychological and social needs of our youngest patients during their medical experience,” Laperle says. “There is a lot of scientific theory and evidence behind what we’re doing.”

CHILD LIFE SPECIALISTS:

Continued on page 11

There are nine child life specialists at the Children’s Hospital at Dartmouth-Hitchcock (CHaD). Seven work in Lebanon and two in Manchester, New Hampshire. “We work with patients from infancy to 18-years old, and help them and their families understand diagnoses, testing processes and how to adhere to treatment plans,” says Laperle. “We’re fully integrated members of the medical team.”

Child life specialist Sonya Charles works with twins

Elyse and Addyson.

11 VALUE-BASED CARE 11

“Parents always know their kid the best, but, in stressful situations, it really helps to have

someone there to help reduce stress and increase coping skills for both the child and parent.”

~ Jessica Laperle, child life specialist

Jeanne "Mollie" Saults, a child life specialist assists Chris, a young patient.

12

Child life specialists are assigned to a unit or service line, and typically receive referrals from physicians, nurses and care coordinators.

“We meet kids and families where they are and make sure that the medical team understands any develop-mental issues that might impact testing and treat-ment,” Laperle says. “For example, we make sure that teenagers aren’t scheduled for treatments at 6 am, a horrible time for adolescents, or that babies don’t have to give up their pacifiers during an X-ray. Small sucking motions are less disruptive than flailing arms.”

One of the most important aspects of the child life specialist's job is to reduce anxiety in patients and families. “Parents always know their kid the best, but, in stressful situations, it really helps to have someone there to reduce stress and increase coping for both the child and parent,” Laperle says. Infants might benefit from holding techniques that allow them to be comforted during procedures. Games that allow practice in holding still or breath-ing help reassure young children. Information often allays the fear of teenagers.

Karen Piacquadio saw the difference a child life specialist can make when her 16-year-old daughter, Kayla, underwent Vertebral Body Tethering (VBT) surgery, a minimally invasive procedure that corrects scoliosis, at Dartmouth-Hitchcock (D-H) Lebanon. “Kayla gets really quiet when she’s nervous, and she was so quiet when we got to D-H,” says Piacquadio. “Slowly but surely, thanks to the calm approach of Mollie Saults, her child life specialist, Kayla began to ask questions and relax.”

A child life specialist for just three-and-a-half years, Mollie Saults is already a social media sensation, at least in the world of Vertebral Body Tethering. “I learned about Mollie on Facebook,” says Piacquadio. “There’s a group for parents of kids with scoliosis and another mom wrote that Mollie had been an essential member of the team—a godsend. Vertebral Body Tethering is a surgery. Kids get really nervous.

But when Mollie gets done, they’re feeling pretty good.”

The Piacquadios arrived at D-H the day before Kayla’s surgery and Mollie was there to meet them. “I gave them a tour of all the places Kayla would be and explained what would happen in each,” says Saults. “Then we talked about what Kayla could expect after the procedure and during recovery.”

“Mollie asked Kayla if she wanted to know details and she did,” says Piacquadio. “Being prepared was such a huge benefit for her. The doctors were great, but they just don’t have time to answer questions about things like the funny underpants you’ll have to wear, and how the anesthesia needle will feel.”

Reassured by Saults’ calm manner and the informa-tion she provided, Kayla slept well the night before surgery. When she woke up from anesthesia, Saults was the first person she asked for. “You can’t put a price on that,” says Piacquadio.

Laperle points out that, by helping to calm patients, child life specialists not only reduce the stress of hospital visits, they can simplify procedures and reduce risks. “We had a young patient who had to undergo a series of MRIs,” says Laperle. “Her parents worried about claustrophobia so the child was always sedated. We gave parents exercises the child could practice at home, and pointed out a website that allowed her to experience the noise before the procedure. She was able to have an MRI without sedation, and was so proud. Less medication meant less risk, and also lower costs.”

Child life specialists continue to support kids as they progress through pediatric treatment, often attend-ing the first visits with adult providers to ensure a smooth transition. “I wanted a career that allowed me to do something valuable that really made a difference,” says Saults. “I feel so lucky to work with physicians and nurses to support our young patients and their families.”

VALUE-BASED CARE 13

Self-management programs help patients live a healthy life with chronic health conditions.

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Living with Chronic Health Issues

But she doesn’t joke about the chronic pain, which kept her out of work for a year. “There were some days where I could barely get out of bed,” she says. Gerow’s primary care physician referred her to the DHMC workshop, “Living a Healthy Life with Chronic Pain,” which is led by Primary Care Health and Well-ness Coaches Andrea Z-Covey and Inger Imset at DHMC’s Heater Road building.

The chronic pain workshop is one of two that are regularly offered by Z-Cov-ey and Imset; the other is “Living a Healthy Life with Chronic Health Con-ditions” and a third, “Living a Healthy Life with Diabetes,” is being added in early 2017. The pair are master trainers for these patient self-management programs, which were designed by the

Stanford Patient Education Research Center. Christine Dyke, coordinator for DHMC’s Health Coaches/Peer Leadership program, says the Stan-ford method was chosen because “it is evidence-based. We were also able to embed Inger and Andrea in Primary Care, giving them direct access to clini-cians and staff for referrals. We thought this would provide a great opportunity for success.”

Dyke notes that the workshops are part of Dartmouth-Hitchcock’s (D-H's)Popu-lation Health initiative, which focuses on giving patients and community members the tools they need to lead healthy lives and to, ideally, stay out of the hospital. “Diabetes and obesity are at an all-time high, and we’re at a point where one in

five people will die of a lifestyle-related disease,” Dyke says. “These workshops provide the nutritional and lifestyle guidance that people desperately need, and help them find a supportive path to healthier and happier lives.”

The six-week workshops meet weekly for 2-1/2 hours, and participants learn about exercise and diet (the Stanford method stresses portion size using the “My Plate” method), and lifestyle chang-es that will help them lead healthier and more active lives. Over the past two years, they have had nearly 150 work-shop participants and led workshops not only at DHMC, but also at D-H’s Lyme Clinic; the Lebanon Senior Center; the Upper Valley Haven in Hartford, Vermont; and the Veteran’s Administra-

Thelma Gerow can pinpoint the exact day when her pain began. “December 6, 2005,” she says. That was the day she fractured her back in a fall. Four days later, she sustained a ruptured spleen and a hole in her small intestine following a car accident. Gerow underwent abdominal surgery at Dartmouth-Hitchcock Medical Center (DHMC) that month, followed by back surgery two months later. “I’ve got hardware and screws holding my back together. I’m half bionic!” jokes the spunky 75-year-old from Perkinsville, Vermont.

Continued on page 17

POPULATION HEALTH 15

Peer-led Workshops = Success“One of the great things about the Stanford method workshops is that they can be run by peer facilitators,” says Christine Dyke, coordina-tor for Dartmouth-Hitchcock’s Health Coach-es/Peer Leadership program. “This makes the program sustainable and easier to spread out into the community and throughout the Dart-mouth-Hitchcock (D-H) system. And partici-pants really enjoy the peer-led groups because everyone is in the same boat; they understand what each other is going through.”

Rhonda Martin of Hartford, Vermont, is one of the peer leaders for the “Better Choices, Better Health” workshop. A retiree who worked in Dartmouth College’s Athletics and Physical Education Department for 44 years, she initially got involved with the D-H workshops as a participant, after being diagnosed with diabetes three years ago.

“I went through a strict diabetes workshop at D-H’s Lyme Clinic and then got invited about a year later to a Dartmouth-Hitchcock Medical Center (DHMC) workshop for people with chronic diseases,” says Martin. “It was wonder-ful and I got so much out of it. So when they asked me if I wanted to be a peer leader, I said

yes because I really wanted to share the tools and information I’d learned.”

Martin completed the four-day training program in April 2016 to become a certified Stanford patient self-management program trainer. Since then, she has led three workshops, including two at the Upper Valley Haven in Hartford, Ver-mont, and co-leads the workshops with either another peer facilitator or Inger Imset and An-drea Z-Covey, who supervise the peer workshop leaders. In November, Martin also completed additional training in Concord, New Hampshire, so that she can lead the new diabetes work-shops, which will launch in early 2017.

“One person in the last workshop I led said it’s nice to be able to talk in a group with people who have similar problems,” says Martin. “They don’t feel so alone in what they’re dealing with on a daily basis and I can share my personal experiences as well. I’m really enjoying it.”

Thanks to funding from a D-H Population Health Innovation Fund grant, Dyke says they are working on a toolkit that will enable the Stanford workshops to be easily started at other D-H sites.

Inger Imset, left, and Andrea Z-Covey, right, both primary care health and wellness coaches, lead workshop attended by patients and community members.

16

tion Hospital in White River Junction, Vermont. “We’re trying to get closer to where the patients are and make it possible for a wide range of people to participate,” Dyke says.

Gerow was skeptical when she started the workshop for chronic pain suffer-ers. “I thought their suggestions, such as exercising to manage pain, were totally useless and would only lead to more pain. But, my diabetes was totally out of control, and I wanted to lose weight, so I decided to give it a try,” says Gerow, who concurrently partic-ipated in another DHMC workshop, “Managing Pain Before it Manages You,” taught by Laura Cottle.

She kept pain and food journals, as Imset and Z-Covey suggested, tracking what she ate and noting the activities that made her pain worse or helped al-leviate it. She made weekly action plans and started exercising by walking her dogs twice a week, eventually working up to walking every day for about a mile. “For a long time I didn’t do much walking or very much of anything, partly because I was in a back brace from my waist to my neck,” she says. “But I no-ticed that just moving helped and that exercise actually relieved the pain.”

Gerow also embraced the other workshop suggestions, which included physical therapy, deep breathing exercis-es and relaxation therapy. “We were amazed at how she threw herself into it because, quite frankly, she was the biggest disbeliever going into it,” says Imset. “It’s been wonderful to see what she’s accomplished.”

Gerow seems astonished by her transformation. She lost more than 120 pounds through exercise and diet changes, improved her insulin levels, and is no longer taking prescription pain medications. “I surprised myself by believing that I could take responsibility for my circumstances and control my wellness,” she says. “I honestly never thought I would have a reduction in pain. But I found that I just really had to make a lot of changes and that has made a big difference in how I feel. Now I get out of bed at 4:30 every morning, get going with housework and taking care of my pets, and I still sometimes work 72 hours a week with the developmentally disabled.”

Julie MacAdam was inspired to start mov-ing again after participating in the “Living a Healthy Life with Chronic Health Con-ditions” workshop. The 47-year-old Leba-non resident is diabetic and has suffered from fibromyalgia for more than 20 years, and wasn’t able to exercise at all just a year ago following a fall. She started her action plan by marching in place during commercials while watching television and has progressed to walking for longer periods of time five days a week, often in DHMC’s hallways. To improve her balance, she also takes a twice-weekly Tai Ji Quan: Moving for Better Balance® class offered by DHMC’s Rehabilitation Medicine Department, which is taught by physical therapists Dawna Pidgeon and Mary Ellen O’Brien. In the process, Mac-Adam has lost 80 pounds, eliminated her narcotic pain medication and cut back on her insulin dose.

“I take a third of the medication that I used to take,” says MacAdam, whose blood sugar readings are now in the normal range due to her weight loss. “Having less stress on my joints has made a tremendous difference because my rheumatologist confirmed that every pound you lose takes three pounds of pressure off your knees. So that’s 240 pounds of pressure off my knees. My knees are pretty happy right now!”

“It has been a joy to watch all the work Julie has done to make her health bet-ter,” says Patricia L. Min, MD, a DHMC general internal medicine physician and MacAdam's primary care physician.

“The workshops are a great way for peo-ple to be in a room full of their peers,

people who understand them and their health conditions and to realize that they’re not alone,” says Imset, noting that the workshops are open to any-one in the community. “We talk about people’s barriers to self-care and then throw it out to the group so they can problem-solve together. So they learn from us, but also from each other.”

D-H’s Vice President of Community Health Sally Kraft, MD, MPH, notes that clinical evidence shows peer support leads to improved patient outcomes. “These classes also build from Dart-mouth-Hitchcock’s culture of engaging patients as partners in creating health,” she says. “We want to provide patients with the skills and the knowledge so they can confidently manage their health needs. This is the right thing for our patients and our community.”

“I honestly never thought I would have a reduction in pain. But I found that I just really had to make a lot of changes and that has made a big difference in how I feel.”

~ Thelma Gerow

Thelma Gerow, left, with Inger Imset

POPULATION HEALTH 17

A SMALL PIECE IN THE PUZZLE OF ALSDavid Scheuer spent much of his adult life sailing on Lake Champlain in Vermont. He never imagined his love of the lake might one day be linked with a devastating illness—Amyotrophic Lateral Sclerosis (ALS). While no single factor can be blamed for Scheuer developing ALS at the age of 63, a growing body of scientific investigation points to it may be from cyanobacteria—algal blooms that grow in waters all over the world—which is a possible risk factor. A generous gift by Scheuer’s family is now funding research examining the connection.

David Scheuer’s symptoms began in early 2014, when his life partner, Glynda McKinnon, noticed that he was slur-ring some of his words. By summer, Scheuer noticed he was having difficulty pronouncing certain words. Then, in September 2014, after months of medical

tests, he received the diagnosis that he and McKinnon had feared—Amyotrophic Lateral Sclerosis (ALS).

The two had spent seven years together. Scheuer was a successful real estate de-veloper, passionate about building healthy,

walkable communities. In his younger years, he had been a nationally ranked downhill skier. McKinnon filled her days working as a director of major giving for what is now Vermont PBS, caring for the horses she and Scheuer enjoyed riding, and staying involved with her three adult chil-dren. The diagnosis changed everything. As Scheuer’s ALS took hold of his body, McKinnon became his primary caregiver.

“To say the journey was dark does not even begin to address how humiliating the last months of Dave’s life were for him, a man who, in some ways, was larger than life,” says McKinnon. Yet she’s thankful for the tender care she was able to provide him: “It meant so much to me to be able to care for him, to be able to face this disease, together, on a very intimate level.”

By mid-summer 2015, Scheuer was strug-gling to walk, eat, and simply breathe. In ALS, certain nerve cells that control the muscles in the body slowly die, even-tually causing complete paralysis. Only about 1 in 10 people with ALS have a family history of the disease; the cause for most people, including Scheuer, is unknown. Many theories exist, including a suspected association with long-term exposure to cyanobacteria, also called blue-green algae.

Scheuer held on until McKinnon’s birthday, August 4. On August 5, he chose to end his suffering, employing Vermont’s Patient Choice at End of Life law, following a plan that he had discussed with his primary care doctor months before.

PHOTO DARIA BISHOP18

A SMALL PIECE IN THE PUZZLE OF ALSCOMPASSION AND KNOWLEDGE

“Dave was very clear how he wanted to live his life and how he wanted to die,” says McKinnon. “He knew that he didn’t want to prolong the illness. Still, he wanted the best care possible, which led him to the Dartmouth-Hitchcock ALS Clinic and neurologist Elijah Stommel.”

Dartmouth-Hitchcock’s ALS clinic pro-vides multidisciplinary care for individuals living with ALS: neurology, pulmonary medicine, nutrition, speech therapy, physical therapy, occupational therapy, nursing and social worker assistance to help manage some of the challenges associated with the disease. Nationally, about 2 in 100,000 people are diagnosed with ALS in the U.S. each year; between

the ages of 55 and 70, the rate is much higher—about 1 in 300.

“The care at Dartmouth-Hitchcock was remarkable and always very professional,” says McKinnon of Scheuer’s experienc-es. “He felt that there was compassion for him and knowledge, which was very important to him. His visits with Dr. Stommel ended up being more conver-sational than clinical. They got to know each other as people. They realized that they shared many of the same interests and passions—specifically music. Dave often said that the best part of having ALS was meeting Dr. Stommel.”

Among the topics they discussed was Stommel’s research on the possible connection between ALS and cyano-

bacteria. Stommel, a professor at the Geisel School of Medicine at Dart-mouth, and other scientists world-wide suspect that long-term exposure to neurotoxins produced by certain species of blue-green algae may trigger ALS in some individuals. A generous gift in Scheuer’s memory from his family’s foundation is now helping to support Stommel’s work.

ENVIRONMENTAL CONNECTIONS

The most compelling evidence implicating blue-green algae comes from studies in Guam, where rates of neurodegenerative diseases were once very high. The native foods were found to contain high concen-trations of a particular blue-green algae neurotoxin called BMAA, which was also

found in the brains of natives who died from neurodegenerative diseases.

Stommel first began investigating the blue-green algae connection in 2008, when he noticed that many of his ALS patients lived close to Lake Mascoma in New Hampshire, a lake known to have algal blooms. In 2009, Stommel and his collaborator Tracie Caller, MD, also a neurologist at D-H, published a scientific paper showing that the incidence of ALS for those living near the lake was 25 times higher than expected for the population there. In a more recent study,

POPULATION HEALTH 19

the team found high levels of the neurotox-in BMAA in brain samples from a large fish from the lake. Stommel’s lab has also found cyanobacteria in the lungs of patients who have died of ALS and others without the disease who live near waterbodies.

Through a collaboration with researchers at the University of Vermont supported by grants and philanthropic funds, Stommel’s team is examining samples of lung and brain tissue from patients who have died from vari-ous causes. They’re looking for an association between cyanobacteria in the lungs and neu-rodegeneration in the brain. In a small study, they found such an association in patients who had lived within a quarter-mile of lakes; no similar association was seen in patients who lived farther from water bodies. Larger studies with more tissue samples are needed to prove the correlation.

Stommel and Caller have also teamed up with geographer Nathan Torbick, PhD, to map areas of higher-than-expected rates of ALS and lake water quality in northern New England. They have found that, in general, ar-eas with poor lake water quality—conditions conducive to algal blooms—were significantly more likely to be ALS hotspots. Likewise, areas with relatively good lake water quality

were significantly less likely to have high rates of ALS.

One of the maps, in particular, is startling for anyone who has spent years on the shores of Lake Champlain’s Shelburne Bay, as Scheuer did. A bright red swatch, signifying a hotspot for poor water quality and ALS, blankets that region of the map.

“Dave really did believe that there was some connection,” says McKinnon.

However, Stommel stops short of calling long-term cyanobacteria exposure a definite risk factor for neurodegenerative diseases. The sci-ence is “becoming more and more interesting,” he says, but it’s notoriously hard to prove that any particular environmental toxin, especially one that is so common, is a significant risk factor for a neurodegenerative disease.

“With most cases of ALS, there are probably genetic predispositions and then on top of

Neurologist Elijah Stommel, MD, investigates the link

between ALS and blue-green algae, which often

causes beach closures, like the one pictured, here, on

Lake Champlain.

BEACH PHOTOS DARIA BISHOP20

“So, basically, I have two goals. One is to raise money for Dr. Stommel to continue his research, which Dave and his family supported wholeheartedly. And secondly, to raise the awareness on the research linking cyanobacteria—blue-green algae—to neurodegenerative diseases."

~Glynda McKinnon

that, there is some environmental influ-ence,” explains Stommel. “That’s no sur-prise. That’s what we see in cancer, too. As with cancer, it’s probably not one environ-mental hit but multiple over a lifetime.”

In an effort to test the cyanobacteria risk theory and to identify other environmen-tal and lifestyle risks for ALS, Stommel and his team are expanding their re-search beyond Northern New England. They recently received a grant from the Centers for Disease Control to examine ALS cases in Ohio and possible clusters around Lake Erie.

If toxins from blue-green algae proves to be a driver of ALS and other neurodegenera-tive diseases, Stommel envisions that one day people may be able to be tested and treated for the toxins. But it will likely take years of research and clinical trials, as well as significant funding, to get to that point.

RAISING AWARENESS AND DOLLARS

For McKinnon, Stommel’s research has inspired her to take action now. “When Dave passed away, I realized that I couldn’t just go on living my life without

sharing the evolving science on ALS and the environment. I feel there is a need to educate the public around the envi-ronmental risks of blue-green algae,” she says. In 2016, she co-hosted two research symposiums featuring Stommel and other scientists in Shelburne, Vermont. She’s also reaching out to legislators, the environmental community, and other concerned citizens in her region to raise awareness in Vermont and beyond.

“So, basically, I have two goals,” says McKinnon. “One is to raise money for Dr. Stommel to continue his research,

which Dave and his family supported wholeheartedly. And secondly, to raise the awareness on the research linking cyanobacteria—blue-green algae—to neurodegenerative diseases.

“I have taken a small piece of a very large puzzle,” she adds. But she’s clearly up for the challenge.

To learn how you can support ALS research at Dartmouth-Hitchcock, contact Richard Peck at Richard.C.Peck@Hitchcock.org or call 603.653.0735.

BEACH PHOTOS DARIA BISHOP POPULATION HEALTH 21

Construction is well underway for the new Jack Byrne Center for Palliative and Hospice Care scheduled to open late in 2017.

AMONG THE MANY LESSONS that Jennifer Brock learned from her mother, Gertrude Huber Mertens, was a deep sense of caring for one’s community.

“My parents cared about people, and I feel exactly the same way,” Jennifer Brock once explained in an interview. “I love being part of peoples’ lives.” Now, in memory of Gertrude and her legacy, Jennifer and her husband, Peter, have pledged $2 million in support of the Jack Byrne Center for Palliative and Hospice Care; the center’s northern inpatient wing, consisting of six patient rooms, will be dedicated in honor of Gertrude.

COMPREHENSIVE, HOMELIKE CARE

The Jack Byrne Center will provide comprehensive care in a homelike setting for patients with life-lim-iting illnesses who are enrolled in hospice but whose pain or other medical needs are difficult to manage at home. The Center will be operated jointly by Dart-mouth-Hitchcock and the Visiting Nurse and Hospice for Vermont and New Hampshire. The Center will also serve as a resource for families caring for their loved ones at home and as a hub for education, training, and research to strengthen palliative and hospice care

region wide. A gift of $10 million from the Jack and Dorothy Byrne Foundation helped launch the creation of the Center, which is scheduled to open late in 2017.

The inpatient rooms in the Jack Byrne Center are de-signed for optimal comfort and privacy, while still facili-tating advanced medical care. Large enough for visiting family and friends, the rooms will also feature private balconies, accessible even to patients who are confined to a bed. The homelike atmosphere and family-friendly features of the center certainly would have appealed to Gertrude, to whom family and community were so dear.

A Shared Value Inspires a Gift to the Jack Byrne Center

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A TRADITION LIVES ON

An extraordinary philanthropist, Ger-trude and her husband, Robert, gave generously during their lifetimes to Dartmouth-Hitchcock and Dartmouth Medical School (now the Geisel School of Medicine), establishing two profes-sorships and the largest scholarship endowment at the school. Jennifer and her husband, Peter Brock, have carried on that tradition, supporting medical education, patient care, healing arts

and cancer care. The Brocks recently pledged another $2 million to scholar-ships at the medical school.

The Brocks’ gift to the Jack Byrne Center is an especially fitting tribute for Gertrude, who directed much of her giving to health care. Her philanthropy played a pivotal role in the creation of Mertens House, a 14-bed nursing facility in Woodstock, Vermont. While Mertens House is a long-term care facility, the length of stay for patients at the Jack

Byrne Center will be, in most cases, a few days. For some patients, the Center will be a stepping stone to returning home, and for others, a place to come when medical needs exceed what’s possible through home hospice care.

Meeting the needs of the commu-nity continues to be a top priority for the Gertrude's lineage—and for Dartmouth-Hitchcock and VNH. It’s a shared value that lives on, generation after generation.

“My parents cared about people, and I feel exactly the same way. I love being part of peoples’ lives.”~ Jennifer Brock

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Snapshots in Giving

The generosity of donors is vital to Dartmouth-Hitchcock’s mission of advancing health through research, education, patient care and community partnerships. Thanks to all who help us sustain our mission.

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A GIFT OF GRATITUDE TO NURSING EDUCATIONMichael Vermouth loved spending time on Newfound Lake in New Hampshire, paddling in his handmade wooden kayak with his dog, Brady; however, he spent much of the last two years of his life in the inpatient unit of 1 West at Dartmouth-Hitchcock Medical Center, as he underwent two bone marrow transplants in hopes of beating his cancer. Still, he died in August 2016.

His wife, Sandra, and their four daughters say it was the oncology nurses on 1 West who made Vermouth's time bearable. They recently made a gift to the Oncology Nurses Education Fund at Dartmouth-Hitchcock, to support continuing education for nurses who wish to advance their training.

“Michael had the best of care with Lisa Wesinger, one of his nurses, as the head cheerleader,” says Sandra. “Dr. Chris Lowrey and the entire staff of 1 West cared for Michael as though he was the only patient. The team did their utmost—angels that they are—to keep him comfortable throughout his ordeal.”

“The care and treatment that my dad received from the team of doctors, nurses, palliative caretakers, housekeeping, dietary services and everyone that he encountered was phenomenal,” adds his daughter Danielle Donovan. “But what clearly rose to the top was the expertise, empathy, adaptivity, compassion, professionalism, kindness and friendship that the oncology nurses provided to our father—and our mother. We are eternally grateful.”

FIGHTING OPIOID ADDICTION FOR HEALTHY MOMS AND BABIESWith an estimated 8 to 10 percent of births in New En-gland involving a mother with opioid use disorders, there’s an urgent need to improve prenatal care for these women and babies. A three-year, $127,000 grant from March of Dimes’ New England Chapter to Dartmouth-Hitchcock’s (D-H's) Perinatal Addiction Treatment Program (PATP) is beginning to address that need regionally.

Through PATP and the neonatal abstinence syndrome program at the Children’s Hospital at Dartmouth-Hitch-cock, D-H provides comprehensive care to pregnant and postpartum women with substance use disorders and their newborns. This approach has led to increased participation in prenatal care, healthier pregnancies, fewer pre-term births, fewer newborns requiring treat-ment for neonatal abstinence syndrome and increased patient satisfaction. Now, with the March of Dimes’ grant, D-H and the Northern New England Perinatal Quality Improvement Network are working with eight obstetric practices in New Hampshire, Vermont and Maine to implement best practices for pregnant women battling addiction.

“There are established guidelines on the best way to care for these women and their babies. The challenge, as with any guidelines, is implementation,” says Daisy Goodman, a certified nurse midwife within PATP. The March of Dimes grant is fueling the creation of a standard “toolkit,” with resources such as care checklists, forms, and proto-cols that obstetrics practices in the region can use right away to improve their care.

“Concern about the impact of drug use on their pregnan-cies is often the primary reason these women seek care,” Goodman says. “That’s an opportunity we can’t miss. The goal of our work is to support healthy moms who are caring for healthy babies.”

To support the work of the Perinatal Addiction Treat-ment Program, visit d-h.org/donate/PATP.

IMAG INE

Imagine a health system that focuses on health, not just health care

Imagine a health system where care is based on value, not volume

Imagine a health system grounded in population-based strategy, not market share

Imagine a health system that rewards quality, not quantity of procedures

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Imagine highlights Dartmouth-Hitchcock’s leadership role in providing the best in patient care, translational research, medical education and community service. The stories featured in this publication exemplify our mission to create a sustainable health system to improve the lives of the people and communities we serve, for generations to come.

IN THISissuePOPULATION HEALTH

Working to improve breast cancer

outcomes through exercise,

nutrition and community.

VALUE-BASED CARE

Child life specialists help parents

and children navigate their care.

PATIENT STORY Nicola Felicetti shares her patient

experience story.