Posts Categorized: Care teams

A Culture of Respect

In a recent Washington Post article, reporter DeNeen Brown wrote about how Aretha Franklin’s classic song Respect took “a man’s demand for respect from a woman when he got home from work and flipped it.“

Everyone deserves respect. And yet, as we go through life, it’s easy to see that some groups need to fight more for it than other groups. Aretha sang, as a black woman, demanding respect, a message she belted out with gusto.

In my time working with older adults at Iora Health, it’s been very clear that older adults are another group that too often have to fight for respect. While some belt it out, many have resigned themselves to a life where they don’t feel respected and give up trying to get what they deserve.

At Iora, I’ve had the honor of speaking with countless older adults – patients and otherwise – to understand what’s important to them and learn how Iora and our care teams can help them live better lives. It’s surprising to me that more often than not, one of the most common answers I get when asking folks what’s important to them from their doctor is time. They want less time waiting for an appointment, less time in the waiting room and more time with their doctor and care team. A lot of doctors say they give their patients more than the average 7-15 minute appointment, but patients still aren’t satisfied. So are the patients not getting the time,  or is there something else going on?

I’m betting on both. At Iora, our teams spend more time with our patients than a typical doctor’s office – as much time as each patient needs. The extra time is key. But the real magic is what happens during that time. During the time our teams spend with patients, they are able to build meaningful relationships that engender trust and openness. Our patient relationships are built on this trust and, perhaps, more importantly respect.

One woman in one of our Arizona practices explained to me what she is looking for in a doctor’s office:

”I want them to listen to me. And not treat me like I’m… ‘she’s an old lady, she doesn’t know anything…because a lot of people I know have gone to the doctor and the doctor just blew them off…I want you to listen and be nice and don’t act bored. And if I’m wrong, explain to me why I’m wrong. And if I’m right, tell me I’m right. And I realize that not everybody is willing to listen ….”

I’ve encountered this theme over and over and over again in my conversations with older adults. While most people, no matter their age, would say that they want more time with their doctors, it turns out that isn’t enough. Most people under 65 don’t have to say that they are looking for someone to be nice, not act bored and explain things. People 65 and older shouldn’t have to either. Everyone deserves to be listened to and respected. I came to work at Iora – and stay here – because this is exactly what we do for all of our patients.

Values in Action: Addressing Needs in Venezuela

At Iora Health, our mission is to restore humanity to health care. Each day, our teams lead the way by showing courage, creativity, empathy, humility and passion.

We see these values embodied in large and small ways every day. A compassionate encounter with a patient, an empathetic ear for a colleague, or recently, through a passion project by an Iora employee.

Gabrielena (Gaby) Alcala, director of Medicare Risk Operations, saw the decline in quality of life in Venezuela with her own eyes. Her father was ill and she saw the struggle to get his basic medical supplies. Unfortunately, his situation was not unique in Venezuela. Once-controlled diseases like diphtheria and measles have returned due to insufficient vaccines and antibiotics and Venezuelans suffering from chronic illnesses like cancer or diabetes must often forgo treatment for lack of supplies.

Motivated by the struggles of Venezuelans to access basic healthcare, Gaby reached out to her fellow Iorans for aid. The response she received was overwhelming.

In an email to Iorans, she described how Venezuela is experiencing one of the biggest humanitarian crises in the world. She shared that Venezuela is facing an 85 percent shortage of medicine, an economic crisis, severe hyperinflation and food scarcity. She contrasted this with the United States, where two out of three dispensed medications go unused and are discarded. National projected costs range from $2.4 billion to $5.4 billion in wasted prescriptions.

Gaby had a simple ask, “Do you have unused prescriptions or medical supplies you can donate?”

Here are some of the responses:

“I have a box of things that I’d like to go to a good cause!”

“Thank you for finding this opportunity for us, we really appreciate the honor to be able to do this.”

“I would much rather send to places that need things than throw things away.”

“Definitely!! Thanks for reaching out to the practices. Perfect timing too for our Earth Day efforts…love it!”

“This should be something that happens every six months so that things don’t go to waste.”

Gaby coordinated the supply donation to the Programa de Ayuda Humanitaria para Venezuela, which has strong ties with health providers and hospitals in Venezuela. With the program’s aid, the items were sent to where they were needed most. Now, Iora Primary Care practices are aware of the donation opportunities for unused medical supplies and can continue to support places in need on a regular basis.

There is a tradition at Iora Health that on your company anniversary you can reflect on your time at Iora. In Gaby’s reflection she said, “I have learned many things during my tenure at Iora, but the most important one is that I work with the kindest people I have ever met.”

Everyone rallying together in support of Venezuela demonstrated Iora Health’s mission and the passion that Iorans bring to their work every day.

 Thank you to Gaby and the local care team members for their efforts! It’s inspiring to work with you!

Ellsworth-Team-Venezuela-DonationsEllsworth-Team-Venezuela-Donations (3)
Interested in joining a team that is committed to making a difference? Check out our current job openings and apply!

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.

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.

One Coffee at a Time

The work we do is challenging and sometimes it is easy to succumb to feelings of doubt, thinking that all our hard work is in vain. However, there are examples that highlight the difference we make. One such example is one of our Health Coaches, Vero’s, most challenging patients.

She is a 23 year old patient. When she came to us it was clear that she was suffering. She has type 1 diabetes, difficult enough for a young adult to handle yet she also suffers from ulcerative colitis. After an extended hospital stay and major bowel surgery, she was left with an ostomy, a difficult situation for anyone and particularly debilitating for a 23 year old.

Her surgeon told her she would have to get her sugars under controlled before they would reverse the ostomy. Dealing with an ostomy bag was not only a hindrance on her social life, it limited her job opportunities.

Not surprisingly, she also suffered from major depression which became a compounding factor in managing her multiple medical problems. She tried talk therapy but never really felt comfortable opening up. Antidepressants didn’t make a dent. She was mired in despair and despite our efforts to engage her in managing her blood sugars, Vero’s texts often went unanswered. We knew she would spend days in her room, crying and isolating herself. She would frequently break down while at work. We begged her to come in to talk to us.

Finally, one day without prompting, she did. We could tell she was on the edge and didn’t know where to turn. She had decided to put her trust in us as a last resort. She opened up to us and all her emotional and physical traumas began to trickle out. It was a very emotional meeting and it was only the beginning. We offered more therapy from a professional, but she really just wanted to talk to her Health Coach. We decided that coffee with Vero every other week would be a start. She left that meeting only a step back from the edge but she was moving in the right direction.

And then, Vero received a gift of beautiful flowers.

One Coffee at a Time Vero

The note reads:


Over the past couple of months Vero’s coffee meetings have been a huge success. She has shared some of her deepest secrets that have clearly been weighing her down and blocking her from moving forward. She has felt comfortable enough to establish care with Nina, our social worker, so she can get the trained help she needs in dealing with her significant past traumas. From a medical standpoint we are still working on her sugars with the goal of reversing her ostomy. She is by no means a picture of health, but we are taking baby steps, in the right direction.

This patient has been a huge reminder to me that despite the monumental task we have in front of us, we do make a difference in people’s lives, everyday. Because of the unconventional resources we have to help us connect with our patients, we are able to continue to find creative ways to make breakthroughs and put our most challenging patients on the track to leading healthier and more fulfilling lives. I know that there are times we feel like no matter how much we try to help our most challenging patients, that they can’t or won’t change. It is so wonderful to be reminded that by showing our patients that we truly care about them and that we won’t give up on them, our positive attitude can have an impact. Great job Vero!

Bad Medicines

Gerardo Pis-Lopes and Eliot Kristan

Photo: Gerardo Pis-Lopez (left) and Eliot Kristan (right)

Two weeks ago, Eliot Kristan, Iora Health’s Devops and Systems Manager, was in the middle of his week-long on-call rotation when he received a support ticket from Stephen Dahmer, a physician in our Manhattan practice. Stephen wanted help querying our electronic prescription service for a list of our patients taking a specific combination of medications due to a report in the NEJM which concluded that the coadministration of trimethoprim-sulfamethoxazole and spironolactone “confers excess risk of sudden death”.

Unfortunately, the two vendors we use for electronic prescriptions do not provide a way to query a patient panel for those who have a specific combination. But the Iora practice team could go through each drug and cross reference the but that would be time consuming and error prone.

Eliot understood that this manual search was going to be a huge burden on the Manhattan team so he consulted with Gerardo Pis-Lopez, a Senior Software Engineer, who had recently been working on integrations with our electronic prescription vendors (and who happens to sit right beside Eliot). After a quick spike (that means a time-boxed experiment), Gerardo was able to download the medication history for each patient at our Manhattan practice. Eliot provisioned an Elasticsearch system and imported the medication data so that he could quickly build a report for any patients with a history of both drugs. The results indicated that, according to our data, there weren’t any patients in Manhattan with the dangerous combination in our system. Eliot informed Stephen and our Chief Medical Officer.

So at Iora, the story wasn’t over. Eliot and Gerardo did not stop with just the Manhattan practice; they decided to do similar work for all our practices. And good thing. They identified 13 patients in total across Iora Health and informed the appropriate teams.

Those teams were then able to very quickly look through 12 patients one at a time (instead of thousands) and determine that only 1 patient was potentially at risk for the interaction. Our care team contacted the patient and confirmed that he was not taking the combination.

An Iora physician reads about a newly published drug interaction, submits a support ticket and our tech team was inspired and empowered enough to spring into action to check on our patients nationwide. Only hours after first becoming aware that this interaction existed, we had a care team on the phone with a patient thousands of miles away to prevent the possibility of sudden death.

One Culture

Iora’s culture is something that is hard to define but I believe it is rooted in a desire to serve others first and foremost. No need to ask permission or beg forgiveness, Eliot and Gerardo felt empowered to just solve the problem. They were not asked to do this but felt that this was the right thing to do so they both dropped everything and got on with it.

At Iora Health, our product development is centered around cross functional teams consisting of clinical, engineering, design and analytical team members. The cross functional team is empowered to build a solution to a given problem and, at the same time, it is one of many components that help maintain one culture across the company. During the team collaboration, we get to hear about what is good, bad or missing in our systems and, as importantly, we get to see our colleagues using them. Those who use the tools we build (patients, health coaches, physicians, etc.) are part of our day to day interaction. Other tech teams don’t often get to have this tight collaboration and because of this, we don’t look at our users like customers but coworkers and patients — people we have an intimate relationships with. This connection is what encourages the behaviour Eliot and Gerardo demonstrated.

I consider myself to lucky to work as an engineer at Iora Health. Not only is the mission of the company noble, I get to create solutions to difficult problems — with people like Eliot and Gerardo — which is rewarding when seeing its impact to ourselves, our colleagues and most importantly, to our patients.

Transforming Health Care One Book Group at a Time

Our ultimate goal at Iora Health is to transform health care. As a Health Coach, I am lucky to work towards this aim daily by building relationships and partnering with patients to address acute concerns, to help manage their chronic conditions, and to support people in reaching their individual health goals.

This is incredibly important, powerful, and gratifying work. Transforming health care is quite a big task so our team needs to be creative every day, always on the lookout for ways to enable this change in – and out – of the exam room.

This creative approach to our work recently led us in a new direction at our primary care clinic in Hanover, NH. We decided to experiment and offer a weekly workshop entitled “Women’s Book Club: Finding Your Own Healthy Body Weight”.

As a company we frequently ask ourselves: How can we connect people who are ready to work on their health? How can we purposefully design interventions that result in creating a healthier overall community?

The formation of a book club seemed to be an innovative and engaging format to address both of these questions. Within several hours of announcing the group in our newsletter, twelve women signed up.

This 10-week session grew out of a weight loss group that had been working together for nearly three years. Recently, the women involved had participated in an online Coursera Nutrition course, had gone walking to increase activity, and even done some simple healthy cooking together. Now, as facilitators, we were looking for a next step, one that would serve to inspire, that was fun, and that would intrigue and engage more participants. Ideally we wanted one that was provocative and different enough to catch people’s attention.

Thus the idea of reading “Half-Assed A Weight Loss Memoir” by Jeanette Fulda was born. This book chronicles Fulda’s journey towards lifestyle change during which she sheds nearly 200 pounds and blogs about it. It is a funny and engaging story that has Jeanette hiding loaves of bread from herself in the trunk of her car, learning to cook, and discovering a love of physical activity she never knew she possessed.

Our intent with the group was to promote discussion and to incite personal action. But how can simply reading a book about lifestyle change actually inspire action in others? This is where Motivational Interviewing entered the picture. We intentionally designed the workshop to mirror a motivational interviewing session (a process that engages motivation within a client to change behavior) and focused on the Stages of Change with participants. During our weekly meetings, participants identified where they fell on the spectrum of change and considered ways to increase their motivation.

At the outset of the workshop, patients were invited to meet with their care team (doctor and Health Coach) to develop a lifestyle approach and food plan that aligned with their health goals. They checked in midway and at the end of the course with their Health Coach to discuss changes – both mental and physical. Book group members were asked to read two chapters each week as “homework” and to reflect on a series of guided questions.

We just completed week ten. Was everyone successful? I don’t know. You’d have to ask them as this depends on individual goals. We shared a lot of laughs, everyone finished the book, and the ladies wrote letters to themselves explaining how their lives would be improved if they made the changes they desired. The cards are in the mail so everyone should be receiving an inspirational note in their mailboxes soon with a reminder to stay motivated.

Did people make behavior changes? Yes! One participant lost 10 pounds. Another started working with her spouse on meals that include more greens and moderation. Some started planning and cooking on Sunday afternoons for the week ahead. The group gelled and formed a strong support network for each other. And they all want to continue.

Did we transform health care? If working with a patient one-on-one in a visit to affect health change is powerful form of intervention, then sitting down with 12 women for an hour every Monday at lunchtime is an extremely powerful way to create change on both an individual and cultural level. We truly can multiply our impact in these group visits. Our team realizes we will only be successful when we work together to affect the culture in which our patients live. Transforming health care is ultimately only possible when we build a community with shared goals and support.

It is energizing to work for a company that encourages creativity and new approaches to help people feel their best. Never doubt that small group of committed individuals can effect change in the world, one book group, one community, one Iora practice at a time. And you might even be surprised by how many people sign up.

Commonality: finding the common threads

Commonality is the state of sharing features or attributes. It’s an amazing thing when that is found when providing a patient care, care they deserve. In October 2013, I remember sitting around the table in room seven at the Culinary Extra Clinic, Iora Health’s first Las Vegas practice that sits in the Stratosphere’s shadow. Every stakeholder was represented at the table: a very sick patient with multiple acronyms using most letters in the alphabet, a sponsor, a primary care physician and a clinical health coach. Each was there realizing this was the most important thing they could be doing at that time.

Let’s go backwards to go forwards. This patient is under 40 years old and is trying to get their second kidney transplant. They quickly became very ill and it was determined the right course of action was to send them to the emergency department. However, an even better course of action involved a direct admission. Direct admissions need cooperation and communication with the admitting physician, all hospitalists and sometimes sponsors.

The roundtable discussion on that fall day allowed the patient to raise concerns with yet another hospitalization. It allowed the health coach, who had the closest relationship to the patient, to provide an additional voice for the patient and advocate for their needs. It allowed the physician to make a sound clinical decision. And, lastly, it allowed the sponsor to witness all of this and provide input.

Everyone at the table had a voice. While it is not uncommon for physicians and sponsors, especially if they are benefit administrators or the insurance company, to have a voice, let’s be honest, at times they may have too much of a voice, too much to say, chastising patients for poor choices and/or costing the system too much money. But what if we all started to sit around the table and voice our questions, comments and concerns. What if the common theme or commonality amongst us is cooperation and communication? How would that change things? How would that change health care and restore humanity to that end?

These are all things to think about, to contemplate. While we do that, please, let us find the common threads amongst us: the desire to be heard, to be cared for and to be respected.

I have been working at Iora Health for over two years now. From day one, I have shared a value with the company and my colleagues to make sure each of my patients feel cared for, seen and heard. I know how to take care of my patients when they step into our office, but when they have to fend for themselves in the Big Bad City on their own….what is a health coach to do?

Luckily for us, we have a whole team of folks in Cambridge that have created our very own software to help us keep track of our patients medical and wellness needs. They constantly revamp our system as needs arise. In my first year, I would document notes in the chart, type in blood pressure readings, make tasks (our reminder system) for myself to follow up on important matters. I knew this data would serve a greater purpose in the long run, but a major pitfall my first year was that the only way to ensure care needs were being followed up was to continually ping myself with reminders. Or hope they would come in on their own and review the chart when they arrived in the office.

As they say, the squeaky wheel gets oiled, and I find truth in that here — the patients I remember best come in often, keep in touch, stay on our radar. However, many patients do not keep in touch and they ought to be on our minds. I used to fear that these patients would fall through the cracks if I did not happen to set a reminder. Year two has upped the ante and empowered all of us. For a year I have been plugging in data and now the software team has given us the gift to use this information to our advantage: we can target specific care needs.

We use the data to show us the general story about our patients so we can learn how to focus our efforts. We call this type of storytelling population health management. I can now plug in certain metrics that I want to see within my patient panel: Who has a BMI out of range, smokes, has had a blood pressure reading higher than 140/90 and is over the age of 40? POOF — a lovely spreadsheet with the patients that fit my criteria pops up. I can filter folks by a plethora of different criteria combinations. I can look at their charts and see if I notice any trends. This new ability to search my patients for specific data points serves as a safety net to my current personal tasking system. This empowers me because I can focus my energies on people who need the attention and we as a team can use our time more effectively to come up with how to focus our outreach efforts.

This summer we took on a major initiative to review, organize data & processes and think about how to best help every patient with an elevated blood pressure in our practice. In the context of a relatively young population without many chronic diseases, we focus on hypertension and other early warning signs for later life problems. High blood pressure generally is not symptomatic until our bodies have taken a beating for many years so it is not often front-of-mind until there is a cardiac episode. We realized we could keep better track of helping patients lower their blood pressure using all the tools at our disposal—coaching around lifestyle changes, counseling and medications.

We began by reviewing their charts but also meeting in teams to consider the big picture of our patients and think about them as human beings with passions and challenges, not just data points. As a team, we came up with some questions we wanted to have answered through information already documented in their charts and minds:

  • What factors are contributing to their high blood pressure (biological, lifestyle, other)?
  • Do they have other cardiac risk factors?
  • How motivated are they to change?
  • What barriers do they have?
  • What is their attitude toward medications?
  • What missing data/markers do we need to get (blood work, blood pressure, etc.)?

Then we came up with criteria for a plan:

  • When will their next blood pressure check be?
  • Where (at the office, home, a pharmacy)?
  • What is the lifestyle/behavior change plan?
  • What is the plan for medications?

This also fits our model better because we believe food and exercise heal just as much as a medication, if not more so for many patients. I have been better able to provide coaching to empower patients now that we have created more structure around the information we gather together and learning more about patient attitudes.

The results were exciting. We reengaged with patients we saw first when we opened two years ago; we made sure patients were up to date on all of their indicated screenings, and we began to have better and deeper conversations about their risk of heart disease and they could do to manage it.

The short-term outcomes were great — our hypertension control rate jumped almost 15%, just from being more organized and using these population management tools. The longer-term outcomes from lifestyle change will take longer to see, but we know we are on the right track!

Knowledge is power. In health care there are many moving parts and copious amounts of information—it takes a whole team to manifest these efforts. At Iora, not only is the doctor thinking of patients, but a whole team is thinking about their health even when they might not be doing the same.