Posts Tagged: Primary Care

Amy Veronneau

Why I joined Iora – A Nurse’s story

As a Registered Nurse, I have played many roles in multiple hospital systems throughout my career. When I worked as a Float Pool Nurse, I supported a multitude of nursing floors, chronic conditions and environments. I discovered that although the hospital is intended to be a place for healing, there are many problems: when a patient is in pain, we push pain medication, and when we see a patient with a chronic condition, we put a Band-Aid on them with medications and temporary interventions—without always taking the time to find the underlying cause. The intentions are good, but the execution is poor, especially when nurses are given so many patients that we aren’t allotted the time to provide adequate education, let alone understand the entire patient situation.

After much frustration with a broken hospital system, I found Iora Primary Care. At Iora, our mission is to restore humanity to health care… and this is so much more than just a slogan. Everyone at Iora takes action to make a difference in the lives of our patients. The patients have longer initial visits with us, where team members spend time with the patient to understand the patient’s goals, desires, support system, and comfort with his/her illness, and we then provide education. We share the medical chart with the patient—which is unheard of at other institutions!

I have finally found a place where I can make a difference….not through pushing medications or through the agenda of the institution I work for, but by working with the patients to help them live their fullest and healthiest lives. I couldn’t be happier as a Nurse at Iora Primary Care.

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A Second Shot at a Second Career

Medicine is a second career for me. I was previously a chemical engineer, but figured out quickly that I wanted a job that allowed me to develop true relationships with others. When I decided to go to medical school, I knew that I wanted to be a primary care physician so I could care for the whole patient, understanding all of the factors that affect their health.

After I completed my residency, I worked for a large outpatient hospital. Each day I fielded complaints from patients about short visits or the fact that they had to have a different appointment for every concern. I was met with the truth that medicine didn’t actually feel like it was about caring for patients–rather, it was seeing over 20 patients a day, in 10-to-15 minute visits. Only seven years after residency, I was debating leaving it all behind.  

In the process of looking for a new job, I posted my resume on physician recruiter sites. I received multiple calls and emails–none of which I answered. Then one day, on my lunch break while eating a protein bar at my desk, I surprisingly answered a call that I knew was from a recruiter. I listened carefully to the man on the other end of the phone as he spoke about a company that was opening new practices in the Denver area; a company that focused on building relationships; a company that wanted to restore humanity to healthcare. That phone call changed my life–I felt like I was getting a second shot at having the career I’d dreamed of.

I went to Denver to interview with the team and very vividly remember the Denver Medical Director telling me: “This job will be more different than you can even imagine.” I visited one of the clinics and got to experience my first morning “huddle”–a team sitting around a table discussing which patients they were concerned about, who was going to follow up on which items, and the strategy for taking care of all patients coming in that day. I shadowed Health Coach visits with patients (without a doctor present) and saw them talk to people about their health concerns, but also listen to their fears, accomplishments, and goals.

I started working for Iora eight months ago and it is hard to describe how much my life has changed. I am part of an amazing team where every person has an important role in patient care. We have time to build relationships so we can understand patient’s health goals, life goals, and the barriers that keep those goals from being reached. We try to activate the patient to become the owner of their health and I no longer strive to see more patients in a day–I strive to take the best possible care of my patients. I went from wanting to leave the practice of medicine, to wanting to change the practice of medicine. To this day, I am still not sure what possessed me to answer that recruiter’s phone call, but I am grateful each day that I did.   

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“What I Will Take With Me”

Dartmouth Health Connect, an Iora Health practice serving employees and family members of Dartmouth College, New England Carpenters Union, and King Arthur Flour, recently received a note from a patient who unfortunately was leaving the practice due to a life change. In her note, this patient described what she will be taking with her as a result of being cared for by the team at Dartmouth Health Connect:

“What I Will Take With Me

  1. I am primarily responsible for my own health with the help of a physician/Health Coach, etc. (collaborators)
  2. Mindfulness is key to addressing/mitigating health issues
  3. Sharing challenges to health issues and weight loss is helpful
  4. If you are sick, believe that you can get better and ask for help quickly
  5. Healthcare is a loving endeavor
  6. The Iora Health care model works”

This letter iterates why the Iora Health care model was created in the first place. We aim to meet people where they are so they can become advocates for themselves in their personal health journey.

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Why Iora Is My System Fit

The first time I walked into an Iora Health clinic, I knew it was different.

This tangible difference was seen in how the team discussed the people they were caring for, not patients. What the company really stands for was demonstrated in the team’s morning Huddle – every team member sitting at a table, hierarchy flattened, creating a mission driven, healthcare family pushing the limits and challenging the status quo.  It was seen in giving people (patients) hugs when they walked through the door and meeting them where they are, in a way that fit their values.  

Iora Health was created to transform healthcare, which is not a small venture. In order to do this, it requires thinking outside the box each and every day.  

We think of how we can create a community for health, not just care for a patient panel. We partner with patients to design classes for their community, and help us redesign how we deliver care. The structure of our model allows teams to make sure that we are measuring the things that matter most to patients, while maintaining high levels of medical quality.  At Iora if it makes sense to coordinate transportation for patients when they can’t get to appointments on their own, then we do it. I have never worked in a healthcare system that designs care based on community needs, rather than what what will be paid for.  

I found myself comparing Iora to my prior experiences in traditional systems; I began to think deeper about the moments when I hadn’t had a chance to huddle with my team every day, or collaborate with patients and their families to change the course of care due to their wisdom and experience. Not having the time for any of this was due to seeing upwards of 30 patients a day and all of a sudden, I knew I had found my system fit.

Today I get to witness and be part of a culture that is passionate about team development and breaking down the barriers of our legacy healthcare system. Iora Health is an organization that many wouldn’t believe exists due to their frustration with the current system.  Before joining Iora, I questioned how I managed to drift so far away from why I went into healthcare in the first place, but this experience has breathed life back into why I’m here and what healthcare is supposed to be. I feel honored to be a part of my team.  I hope others frustrated by the current system see Iora’s view of care as a sustainable way to create the change we are all looking for.

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Full Circle

My inspiration to go into nursing was rooted in an idealistic view of Florence Nightingale, the ‘Lady with the Lamp’, as she carried her lantern and tended to the war’s sick and injured. My original perception of this career path was a melding of thoughts from my home health experience, TV, movies, and school. Through my first nursing job, I learned that nursing is not a glorified woman laying hands on the stricken, but rather really hard work. Work that I found that I loved.

My passion for helping others was founded in a leader I had at my first job as a home health aide before ultimately deciding to become a nurse. My director was an eloquent and skilled Registered Nurse, managing a large homebound elderly patient population, several RN’s, LPN’s and home health aides, like myself. She was directive but kind, making sure that all questions were answered and ensuring that we had everything we needed to care for our patients well. She was happy and patients loved her energy when she arrived at their home for supervisory visits. She encouraged and guided me through my decision to go to nursing school, with the added support of helping me balance both working and going to school full time. I admired her not just for her nursing skill, but for her compassion toward patients and me.

In my first few years of nursing, I noticed that RNs in traditional settings are often treated as the frontline information gatherers or the middleman; tasked with asking questions, placing orders, collecting specimens, starting IV’s, or performing one of the many other duties needed to care for a patient. Developing a relationship is an added bonus, but not part of the job description. After coming to this realization, I thought back to Florence Nightingale and my first director, asking myself, “do nurses ever get the time to really get to know a patient? Can a nurse uncover a problem without worrying about a meaningless 82-question admission assessment?” I got the answer I was looking for when I found Iora Health.

Iora is a place where I can collaboratively run a primary care practice with a physician, care for my patients in a kind and compassionate manner, and help others discover barriers to their own health. It’s a place where my opinion matters because people support one another. This environment cultivates the passion that drives me as nurse.


I am now refocused on the core reason I went into nursing 20-something years ago: transforming healthcare through nursing leadership. This is what nursing is supposed to be – lifting each other up with a culture of helping one another be better caregivers. It’s about meeting patients where they are, seeing the barriers they face and collaboratively figuring out ways to give them the type of care that the ‘Lady with the Lamp’ did 165-years ago or my home health aide director did 20-years ago. I have come full circle, back to my nurse heroes, and I get to be a part of this incredible change.

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Why Iora = Comprehensive Primary Care

Janice* joined Iora Primary Care after moving to the Seattle area from Idaho. In Idaho, Janice had several specialists who she had to see for her many medical conditions. She was pleased to learn that at Iora we do as much care in the practice as possible in an effort to streamline care and save patients from paying unnecessary copays.

Janice came to us with a long history of multiple complex medical conditions, which included chronic pancreatitis, diabetes, vascular disease and long term pain medication usage. Fortunately, one of the gifts that Iora gives their staff and patients is time. We have time to think about our patients from a comprehensive perspective and we ensure that the patient has time with their care team to feel heard and supported on their journey. Janice’s health care team, consisting of a doctor and Health Coach, worked with her to create a plan that would meet her complex health care needs.

We set up a schedule of routine appointments to see the doctor and address Janice’s multiple concerns. In addition, we  set aside time for her to meet with her Health Coach to address diabetes education and customize her medications to better fit her lifestyle. Even though she had been on insulin for years, no one had taken time to teach her about diabetes and how her other medical conditions affected her blood sugar. Through these coaching visits, Janice was able to stabilize her blood sugar and learn about the warning signs associated with it being too high or too low. She called whenever she had questions and, over time, became much more confident in managing her diabetes on her own.  

Beyond diabetes management, we also started working with Janice to address her chronic pain; at Iora we work to balance the need to treat people’s pain with the importance of doing it safely.  Sometimes that means we recommend changes in how people use pain medication and Janice was challenged by the compromises that this process requires. One day after she missed an appointment, I called her and learned that she had left Iora for a different primary care practice. As a team we were sad to lose someone we cared about and who we felt was truly making positive progress and life changes to better herself.

The Turning Point

About four weeks following her departure from Iora Primary Care, we received a call from Janice asking to speak to her former doctor. On the call she said that she realized she had “made a big mistake” and asked if the doctor would be willing to take her back as a patient. She went on to tell us that her new physician told her that in addition to her primary care doctor she would have to see two different specialists to manage her conditions and “I kept hearing in my head my Iora doctor saying ‘we can manage that for you here in the clinic.’ I didn’t want to go to all those other doctors!” Of course we were happy to welcome Janice back to the practice and resume the work we had been doing together towards a healthier, empowered life.

Over the next six weeks, after rejoining Iora, Janice gained new insights into how her choices in life affect her health through participation in one of our chronic disease self management classes. With options like classes, personal meetings with her Health Coach, and visits with her doctor, Janice grew optimistic that her life could become more than just one health crisis after another.

*Please note patient name has been changed to protect identity and private health information.

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Joy in Practice…No More Sunday Scaries!

One Sunday evening about a year ago I was cleaning the kitchen after a family dinner and having a conversation with my daughter. My daughter is typically an energetic, high-spirited individual and was particularly quiet this evening.  

“Are you feeling okay?” I asked.  

She responded with a sigh and shrugged. ”I’m fine, I just have the Sunday scaries!”

This term was unfamiliar to me so I followed up with, “What exactly are Sunday scaries?”

Without hesitation she responded, ”It happens every Sunday around 5 o’clock when you realize that the weekend is over and you have to go to work in the morning.”

My initial response of laughter was quickly overshadowed by sadness that I, too, had the Sunday scaries. Or, more importantly, the realization that I had always had them and hadn’t known it.  As a nurse I have always loved what I do for a living, but at that point in time the joy I felt for what I did for a living didn’t align with my day-to-day job. Little did I know that a few months later everything would change.

Enter Iora.  

On November 12, 2015 I began my journey to transform health care. The following day I boarded a plane and headed to the All Iora Retreat (AIR) in New Hampshire followed by several days of training at the Nest (the affectionate name for our headquarters). Unknowingly, those six days were the introduction to the experience of “joy in practice” and the beginning of the end of Sunday scaries.

At AIR I learned that one of the nine drivers of the Iora business model is joy in practice.  In 2013, Andrew Schutzbank, VP of Product Development, coauthored an article that highlighted 23 high-functioning primary care practices.  The article focused on physicians and the need to mitigate burnout.  Primary care practices were identified based on successful innovations that resulted in high performing teams, which ultimately created joy in practice.

What makes joy of practice possible at Iora is that we veer from the traditional health care model and focus on servant leadership.  Instead of a hierarchical (or “top-down”) model, Iora values equal input from all Care Team members, regardless of “status”.  Servant leaders collaborate with the team, putting team needs as the priority, thus encouraging the team to embrace Iora values and empower them to become high performers. This type of work environment creates a strong sense of ownership by all team members because they feel they have a voice, they’re heard, and are then invested in the outcomes of their work.

The word culture is inserted into conversations on a daily basis.  To Iorans that seven-letter word packs a huge punch and plays a vital role in our joy in practice.  It is the driving force behind the decisions that we make, how we treat each other, and most importantly, how we treat our patients.  Humility, courage, empathy, creativity, and passion are common values shared by all Iorans.  If Joy in Practice had a heart it would be called Culture because at Iora Joy in Practice is not just a catchphrase.  Happy employees are a priority.

One year ago I was educated on the definition of Sunday scaries.  I remember thinking that this was just part of work-life and the main reason that people were so intentional when planning for retirement; they were planning to find their joy.  One year later I can honestly say I have found mine. And guess what? With that realization, my Sunday scaries are no more.

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This is a question that we hear constantly at Iora Health from investors, Care Teams, and especially from electronic health record (EHR) vendors. Why not buy an EHR off the shelf? Why not work with another developer to build what we want? The short answer is, prior to Iora, Rushika Fernandopulle, MD, MPP, CEO and co-founder of Iora Health, tried all of the above; he and Neil Patel, MD, published a paper detailing their poor experience with eClinicalWorks in supporting the type of care we have at Iora today. So with this in mind, why build our own EHR (or as we call it, Collaborative Care Platform) to which we affectionately refer to as Chirp?

Simple. No one else has built what we need and here’s why:

  1. Other systems are too focused on billing, coding and encounters. Modern EHRs are abstractions of the paper record, with an innate focus on a given encounter and the notes/billable claims derived therefrom, rather than the clinical story of a patient.  Each time a patient and doctor meet, every piece of information must be documented in a way that a third party reading it could understand the patient in their entirety. The most crucial elements of care, anything that occurs outside of a visit, any synthesis done by providers, or any changes over time, are effectively lost in the modern EHR.
  2. We lose the story and the relevant data. Within EHRs, data is either too structured, with infinite checkboxes replacing sentences, or insufficiently structured. For example, errors such as a patient’s son who has been listed as seven years old for the last five years are easily overlooked amidst the clutter of the traditional EHR. This structure results in a jumbled patient story, no ability to analyze clinical data, errors propagated with each copy, and a worsened chance of making good clinical decisions.  

OK. How is Chirp different?:

  1. Chirp is designed to support a clinical team that cares for a population of patients. By first emphasizing communication about the administrative aspects of health care (faxes, follow ups, lab reviews, check ins, etc.), teams are able to accomplish everything necessary for their individual patients within one workflow. Chirp shifts us away from encounter-based care, hunting through multiple software systems, toward a work task structure, so that the care of a population can blend in seamlessly with an otherwise busy clinical day. Teams can spend their time in relationship-based primary care, rather than in an endless stream of seven minute visits. Other EHRs have the care of individuals and populations as two separate systems for two separate audiences and completely miss that a population is comprised of individuals who need care.
  2. We need the ability to innovate constantly. The Iora Clinical Model is always evolving. Decisions that made sense in 2012 make less sense in 2016 as we grow and learn. With a third party product, we have no hope of convincing someone else to build what we need. With our own software and amazing team, we have the ability to test things and move forward with changes in real time based on real world experience. This process replaces the slow, usually inaccurate, large changes done in one sitting to a software platform.

At Iora we are building an entirely new model of care delivery; we have been able to innovate payment, team composition, physical space, workflows and of course, our software.  It is the ability to grow all of these elements at once that has led us to create a model of care that lets us truly connect with our patients and help them solve their problems, each and every day. Chirp is a vital part of the puzzle that makes that possible.

Health Coaches, Cori & Audra

Medicine Coupled with Compassion

Modern medicine is incredible. We can give you a pill and lower your cholesterol, give you a pill and lower your blood pressure. We can set a broken bone. We can save lives; we can extend lives. We can fix so many problems. It’s totally amazing.

But then there are all these health problems that biomedicine doesn’t have a quick-fix pill for. There’s no pill for loneliness, and it’s a common problem that definitely affects your wellbeing. There’s no quick answer for losing weight, or getting fit. Balance is a really important issue at our clinic. So many of our patients are afraid of falling and feel unsteady. There’s often not a quick fix for improving balance. I think that most of the time, when it comes to health problems like these, patients are kind of left to go it alone. Part of the health coach role is to support patients with problems that take more time. No doubt they have to put in the legwork, but they don’t have to do it alone.

Sometimes the role of the health coach is just to hear the patient and understand what they’re going through. At the Shoreline clinic we have two patients named Dan and Mary Ann. They have been married for a long time. And it is really obvious when you meet them that there’s a lot of love. They just have a very kind way of interacting with one another.

Dan was diagnosed with Alzheimer’s disease at a fairly young age: in his mid-sixties, which was devastating for Mary Ann. And this last year was particularly hard because Dan’s condition worsened quite rapidly. And as it worsened Mary Ann had to take on more and more caregiving responsibilities.

Audra is a health coach who works in Shoreline with me: Mary Ann and Dan are on her patient panel. For any of you that have been caregivers, you know it can be really taxing work. At one point Mary Ann was sending emails to her health coach, Audra, nearly every day. Often Audra would have really solid advice for her, or something tangible to offer. With the support of Dr. Levine and Debbie Yoro, our clinical social worker, the team provided care that was so far above and beyond the status quo. But sometimes Mary Ann would come to Audra with problems that didn’t have a clear answer. When this happened Audra would just hear her out and be there with her. What resulted was really special. Mary Ann developed a very trusting relationship with Audra and the care team as a whole. It was clear that Mary Ann felt like we were on her side: that we were a team. She knew we had her best interests at heart.

There’s no cure for Alzheimer’s disease. But what is so great about the Iora model is that it recognizes that, yes there is value in fixing people’s problems, but there is also so much value in helping them cope when their problems can’t be fixed. Mary Ann sent us a note recently and it included a quote from the poem ‘Kindness’ by Naomi Shihab Nye. It read, “Then it is only kindness that makes any sense anymore; only kindness that ties your shoes and sends you out into the day.” What I love about Iora is that it’s not just medicine. It’s medicine coupled with compassion. It’s difficult to measure the value of human compassion in medicine. But when you hear stories of real human experiences, it just intuitively makes sense. The care that is provided at Iora is so exceptional partly because we recognize the value of the healing relationship and actively work to foster meaningful connections.

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A part of something bigger

What led me here to Iora? That’s an interesting question. Healthcare was never interesting to me. I went to school for filmmaking and the only real thoughts I had of the health system was that it was expensive. I avoided doctors and hospitals like the plague. Being healthy, I could get away with that.

Then, life changed. I met my husband, a type 1 diabetic, and about nine months later, my video editing job came to an end. After several months of hard thought I realized that while I was pretty good at filmmaking, it wasn’t the right place for me. Not knowing what was, I took a job doing accounts receivable at a Skilled Nursing Facility.

Work was disheartening. I watched families struggle to try and figure out how to pay for rehab and long term care. I called 85 year old widows on social security to tell them they owed money for their time with us while they were trying to figure out how they were going to pay to heat their house that winter. And the worst was the sad realization that the work wasn’t about what was right for the patients, but rather what was best for the facility.

And it was just as disheartening on the personal side. There was a lack of communication between my husband’s doctors. We had little to no support in general, especially when we had to figure out how to do what the doctors prescribed. While his primary care doctor was better than most, she didn’t have the time to spend with him or with his specialists that would have been truly beneficial. We felt like numbers, not names and certainly not people.

We are told from a young age that we can do anything we put our minds to; that we can change the world. But on so many levels, at work and at home, it felt like I was constantly swimming upstream, with someone telling me why we couldn’t do something, why some change or another wouldn’t work. Just three years out of school and I had stopped believing that change was possible.

The spring after we got married, I started looking for a new job. I stumbled across an administrative/finance position at Iora Health. While I had no interest in continuing in healthcare, I needed to pay my bills. Honestly, I didn’t expect much, but when I read the company description, I felt an immediate connection. You could feel the honesty in it. These people believed they could change things.

I applied for the job knowing that I could do about half of what they were looking for, and that I could learn the rest if someone was willing to teach me. I never expected that I would actually get a call, but the next day I received an email asking for a phone screen. After talking to Paul Dufault for a half hour, I was hooked. I dug up everything I could on Iora (which wasn’t much beyond the The New Yorker’s “The Hot Spotters” article), and the more I read, the more excited I got. As the interview process progressed, I realized that I wanted this job more than I’d ever wanted any job. What they were doing made so much sense to me. I never thought about the fact that it was a start up or that in six months I may not have a job, or that they could fail. It didn’t matter to me; I wanted to be a part of this.

When Iora’s Chief Operating Officer, Zander Packard, told me that they wanted to hire me but they weren’t sure when they could bring me on, I told him I would wait. We set up a time to check in in a few weeks. That was in March of 2012 and I started in May and haven’t looked back since.

The past three years have been an incredible journey. I’ve watched the company grow from 30 people with two practices in two states, to 150+ people with 12 practices in seven states. I’ve grow in leaps and bounds as my role evolves. I’ve done everything from ordering lunch and scheduling meetings, to writing company policies and creating processes. I found a company that believes that if you do the right thing, the rest of the pieces will fall into place. The bottom line is important, but it’s not the first thing.

Margaret Mead once said “Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it’s the only thing that ever has.” I never felt that this was a truer statement than I have working with this amazing group of people at Iora Health.