D-H in the Community
Sometimes health care is not about medicine, it’s about helping people access the services and necessities they need to live healthy lives.
This is the foundation of population health management. “We can provide the medical care, but often we don’t know if someone can’t get to the pharmacy, or can’t get food or if they need help getting to their medical appointments,” says Steve Paris, MD, regional medical director, Dartmouth-Hitchcock's (D-H) Community Group Practices: Manchester, Concord and Nashua.
D-H leaders and clinicians understand that community partnerships play a key role in improving population health and people’s lives. To better serve the needs of patients, their families and community organizations across the region, D-H partnered with four neighboring northern New England hospitals to conduct a joint community needs health assessment. Based on the findings, D-H is focusing on the following areas: care for those with limited resources, seniors and those with substance use or mental health issues.
Care for those with limited resources
Last year, D-H provided free or reduced-cost health care services to more than 20,000 New Hampshire and Vermont residents, who lacked insurance and were unable to pay for care. D-H also provided care for more than 71,000 people enrolled in Medicaid. While the investment to provide these services is substantial (see table on page 13), it represents our commitment to provide the highest-quality health care to the region’s most financially-vulnerable residents.
D-H is also collaborating with several community organizations, including the Tipping Points Grants program. Supported by Partners for Community Wellness, the community engagement arm of D-H’s Community Health Department, and administered by four partner agencies, five $1,000 “tipping point” grants were awarded to each agency to help fixable life challenges, like repairing a car for getting to and from work and to medical appointments, or buying clothing that meets the requirements of a job.
When selecting partner agencies, “we looked for sophisticated organizations that serve a wide array of individuals and families and that could cover our geographic scope,” says Partners for Community Wellness Director Karen Borgstrom. “For example, The Upper Valley Haven in White River Junction [Vermont] is very engaged in helping people move toward secure housing and employment. Easterseals New Hampshire, which is headquartered in Manchester, is expansive in our region and offers a broad range of services to a wide range of clients. River Valley Community College in Claremont, New Hampshire, prepares students for good-paying, stable careers. And Families in Transition focuses on the needs of homeless families in southern New Hampshire.”
“Tipping Points is a great model that shares know-how across agencies while lifting up recipients and their families,” says Susan Presberg-Greene, a member of the Tipping Points Steering Committee. “Tipping Points Grants are making a big difference to recipients and their families. The stories are so moving. Supporting the program is a great way to show we care.”
Care for our seniors
As the population of New Hampshire and Vermont ages, we have to identify new ways to support the health and well-being of older adults. D-H is teaming with community support services and making investments in communities through a variety of pilot projects. D-H’s Aging Resource Center also provides patients and their caregivers with a wide array of classes, support groups and family support.
“Thanks to a joint Frail Senior Project between D-H Manchester and Easterseals New Hampshire, we now have a better understanding of the additional assistance needed by some of the highest-risk, elderly patients in the state’s southern region,” says D-H Manchester Care Coordinator Diane Flint, RN. Thirty-five Manchester area patients are enrolled in the program and receive help from licensed clinical social worker Julie Brown-Nierman, LICSW. She performs a wide range of services, such as taking patients to medical appointments, helping them find housing and enrolling them in therapy programs.
D-H is also providing free programming and support to GoodLife Programs & Activities, based in Concord. “Our mission is to be a hub in New Hampshire that compliments existing services and fosters ongoing community engagement by providing programs and activities that support the independence, health and well-being of active adults aged 50 and older in the Concord area and beyond,” says Susan Greenblott, GoodLife’s director of Development and Marketing. “We value our ongoing partnership with organizations like Dartmouth-Hitchcock.”
D-H has sponsored GoodLife events and hosted the New Hampshire Association of Senior Centers Conference. Additionally, D-H clinicians have given free presentations at GoodLife, such as:
- Heart Health for Seniors, with cardiologist Gerard Dillon, MD
- Parkinson’s Disease: Knowing the Signs and Treatment Options, with neurologist Maureen Hughes, MD
- Being Happy At Any Age, with D-H licensed psychologist Juliana Read, PhD
Mary Ann Aldrich, RN, MS, clinical director of Community Health Improvement for D-H’s CGPs, says they plan to expand their work at Goodlife, as well as at senior centers in Manchester and Nashua. The Community Health Improvement Department also recently made a $50,000 contribution to the Manchester Community Health Center, as well as a $65,000 contribution to the Good Neighbor Health Clinic in White River Junction, Vermont, which both serve primarily uninsured and low-income individuals. “As a Community Health department, we’re really looking to identify opportunities where we can educate people and support access to health care in our communities for those who are most likely to experience income barriers to care,” Aldrich says. “We’ve got a lot of great things going on in the southern region of New Hampshire, but there are also exciting partnerships ahead.”
Care for those with substance use and mental health needs
More than 50 percent of the U.S. population will experience mental health or substance use concerns during their lifetime, and almost everyone has a family member or friend who has been affected by depression, mental illness or addiction. D-H is working to embed behavioral health care as part of its Primary Care services. In Lebanon, Manchester and Bedford, Children’s Hospital at Dartmouth-Hitchcock (CHaD) pediatricians regularly screen their teen patients for mental health and substance use concerns, allowing clinicians to partner with teens to catch unhealthy behaviors early and to provide behavioral health care, if needed.
To help combat the growing substance use issues with teens, CHaD pediatrician Steve Chapman, MD, led a multidisciplinary team in developing a project called Adolescent and Young Adult Screening, Brief Intervention and Referral to Treatment (SBIRT). This project grew out of Dartscreening, a program originally developed by CHaD’s Ardis Olson, MD. With support from a New Hampshire Center for Excellence grant, Chapman and his team began piloting the SBIRT tablet tool in October 2014. When adolescents and young adults come to D-H for their annual well-child visits, they are given a set of questions about potential substance use, depression and anxiety, which are integrated into a tablet-based screener that automatically updates in a patient’s electronic medical record.
D-H Primary Care currently has SBIRT programs in Lebanon, Manchester and Bedford, and expanded the program to Concord in the spring of 2017. An expansion to Nashua is also in the planning stages, with a targeted launch date of late 2017. According to Chapman, the population health impact will ultimately be 8,400 adolescents a year.
“Part of the exciting potential is that we see these kids back at least once a year, and so these screenings are not a one-time proposition, but the beginning of an ongoing discussion as they progress through adolescence,” Chapman says.
D-H is also expanding its Perinatal Addiction Treatment Program throughout the region and is subsidizing access to the Outpatient Addiction Treatment Program. As opioid use in New Hampshire and nationwide has skyrocketed, the number of infants born with neonatal abstinence syndrome (NAS) has also grown. By 2016, eight to 10 percent of newborns in the state’s Upper Connecticut Valley region had been exposed to opioids in utero and many had NAS, with moderate to severe symptoms of physical dependence at the time of delivery. To help pregnant women overcome addiction and protect their babies, D-H, the Geisel School of Medicine at Dartmouth and CHaD in 2013 began offering a comprehensive program of care for pregnant and postpartum women with substance use disorders.
The D-H Perinatal Addiction Treatment Program currently treats more than 50 pregnant and postpartum women, and has received national media coverage for its innovative, one-stop approach to substance abuse treatment. Since its inception, the program has demonstrated positive outcomes for its participants, including increased participation in prenatal care, term delivery, fewer newborns requiring treatment for NAS and increased patient satisfaction.
Thanks to a $127,000, three-year grant from the March of Dimes New England Chapter, D-H is facilitating the regional delivery of comprehensive services for pregnant women with substance use disorders. Daisy Goodman, an advance practice nurse with a specialty in midwifery, who works closely with the women in the Perinatal Addiction Treatment Program, will serve as the investigative leader in developing the regional toolkit over the next three years. The toolkit will address the challenges of coordinating care between maternity and addiction treatment providers, as well as between the inpatient and outpatient settings.
Goodman has also been instrumental in helping to bring more nutritious food to the mothers participating in the program. Through a partnership with the Upper Valley Haven, volunteers stock the food pantry and refrigerator of the Perinatal Addiction Treatment Program clinic with staples like eggs, produce, milk and cereal. They also prepare healthy “grab and go” snack bags of fruit and veggies, and casseroles for patients to take home after participating in recovery groups. Kristen Coats, the Haven’s program coordinator of food and wellness programs, explains that this pilot nutrition program was started after she met with Chapman to discuss food insecurity, which is when a household has limited or uncertain access to adequate food. “He talked about how powerful it was to have resources co-located in the same building,” she says.
"And for these young mothers, it’s one less car ride or bus ride they have to take.”
Together all of these programs are part of an overall system that D-H is implementing to improve population health in northern New England, says D-H Director of Community Health Greg Norman. "Dartmouth-Hitchcock has a commitment to work with others to meet the needs of the communities we serve. These projects, and others that we are working on, represent our commitment to partner our people, expertise and resources with human service organizations and others to address conditions that affect health in our communities," Norman says.