Healthcare Musings For 6 December 2019

 

6 December 2019

Dear Interested Readers,

 

Grass Root Efforts To Address The Social Determinants of Health: Introduction To Partners For Community Wellness

 

David Brooks’ recent best seller, The Second Mountain: The Quest for a Moral Life was an inspirational read for me. The link above is to an excellent review written by Mark Epstein, a New York psychiatrist and author. In the May 31, 2019 edition of Healthcare Musings, I described my reaction to this thought provoking book. 

 

Epstein begins his review with a remarkable paragraph:

 

The ego, a necessary construction, can also become a burden. In its unrelenting focus on power, achievement and sensual gratification, it breeds a culture, both inner and outer, of oppression, insecurity, addiction and loneliness. Enough is never enough. There is always someone richer, more accomplished and more successful than you are. Spiritual traditions across the world have offered counsel. The happiness that comes from accumulation is fleeting, they remind us. There is another kind of happiness, let’s call it joy, that comes from helping others.

 

I resonated with the message of the The Second Mountain because by the time I read the book I was attempting to climb my own second mountain. I retired at the end of 2013. There is rarely a good time to retire. Retirement always seemed to me to be a bit like stepping off the road while doing a marathon. Over the years it was occasionally true that I needed to drop out of a marathon despite the fact I had already run twenty miles. On occasion, I dropped out because of the development of some pain that made continuing ill advised. On other occasions, I found that I had started too fast, emptied my reserves, and did not have the stamina to continue on a day when the temperature turned out to be unexpectedly high. Something similar was part of the reality of my decision to retire. I had set goals for myself and for the organization that it was clear I was not going to be able to accomplish. It was obvious that the best thing for the organization and for me was for me to step aside and let someone with a different skill set, or at least someone who had more residual energy, lead the enterprise as it encountered new internal and external challenges. 

 

Retirement was also like stepping off a train and then watch it continue on its journey without you. I could still feel the rumble of the rails in my bones as I watched the caboose move toward the horizon. To mix metaphors, it was also a little like the feeling from childhood of getting off a merry-go-round and experiencing the continuing sense of spinning that made walking a little unsteady. Brooks’ metaphor for that moment in life that I was experiencing, and that so many others also discover, was that I had come down off my first mountain and was in a valley of despair and confusion. 

 

I have heard other people give their own versions of this valley of despair and confusion. Brooks’ has the skill and the artistic talent to describe his own valley in a way that has allowed so many of us to say: “I know that place!  I have been there!” It has been my observation that the valley is such an uncomfortable place that most people immediately begin to try to find another mountain to climb. Brooks’ book is all about climbing that second mountain.

 

When you are in the valley,  you often imagine that you alone. It can feel like you have lost all the connections that enabled you to be successful for a while on the first mountain. Initially, I experienced the sense of “lost connections” in very mundane ways. It occurred to me that for many years I had been supported by fabulous administrative assistants who managed my schedule. Managing my schedule for myself was a skill that I needed to learn. Cheryl Livoli, my loyal administrative assistant for six years, had been “my boss” and my organizational eyes and ears for most of the last phase of my professional life. She was also a great adviser. She would read my weekly letter for errors not only for spelling and syntax, but also for tone and context. I depended on her gentle admonition, “Is that really what you want to say?” In the first few days of retirement without Cheryl’s daily guidance and counsel, I felt very disoriented. 

 

In the valley you quickly discover who your friends are. I have mentioned several times that three weeks after I wrote my first “last letter” my friend and guru from Simpler Consulting, John Gallagher, called me up and challenged me to continue to write. As I thought about what my continuing purpose might be, it occurred to me that sharing with others in writing and on boards what I had learned in my administrative and governance positions was an opportunity that I should not pass up. What I did not realize at the time was that there would also be a satisfying way to employ my “clinical skills.” 

 

One of my old football coaches used to emphasize being aware of where you were on the field. He would say, “Get your head in the game!” One needed to be alert to the opportunity to pounce on a fumble or intercept a pass. If you were where you were supposed to be you might see the opportunity to turn a “busted” play into a gain.  His point was that opportunities come in the most unexpected ways, but you had to be ready to respond. Shortly after we moved to New London, we discovered that we had much too much furniture. My wife posted on a website that we had furniture to offer to anyone who needed it and could pick it up. Not long after the posting went up, we were contacted by a man who said that he was helping a single mom who was fleeing an abusive relationship. She had a job and an apartment for herself and her young son, but she needed furniture. He said that he would like to come with her to look at what we were offering.  That is how we met my friend Steve. I did not know at the time that Steve was well on his way up the trail to the summit of his own second mountain. I am also happy to report that the mom and her son are doing well now in a house they own, thanks to Habitat For Humanity and the helping hands of many people in this community.

 

That was five years ago, and since that time, Steve has been my guide on my metaphorical second mountain as well as on many of our New Hampshire mountains. Currently, I am working with Steve and several other concerned members of our community to establish a new 501c3 that will be called The Kearsarge Neighborhood Partnership. Word has gotten out about the new organization and we are getting calls almost daily from people and agencies who are seeking our help. Many people in our community have needs that are not met by town welfare officers, or some of the established charities in our area. In my mind, the shorthand for our mission is to do what we can to improve the social determinants of health in our community. The current iteration of our mission statement is simple:

 

“To provide social, spiritual, financial and physical support for people in need primarily within the Kearsarge/Sunapee region.”  

 

Our vision statement is also a work in progress even as our work has begun before our 501c3 status as a non profit organization has been finalized. At the moment we are working with:

 

We will help individuals and families move from crises to sustainable lives that are hopeful and have material, spiritual and relational prosperity.  

We will do this by coming alongside people as non-judgmental peers who are there to offer our presence, our help, and if asked, our advice.  We will limit one way giving to crises and seek always to find ways for legitimate exchange. We will not do for others what they are capable of doing themselves and will listen carefully to our partners to understand what they believe they need to thrive.  

 

If you think the statement sounds “faith-based,” it is not. Many of us are “religious,” whatever that means, but we believe that empathy and a desire to be of use to others is a defining reality of personhood and not a manifestation of any one philosophy of life. We admit that we are motivated by the admonition that “Whatever you have done for one of the least of these my brethren, you have done for me…”, and by “…love your neighbor as you love yourself,” but our motivation is to be available to anyone who asks for help. We realize that people are always apprehensive facing problems alone. We have companion charities in our community that are willing to offer money in moments of acute need. Our goal is a longer term effort to help in a variety of ways as requested that go far beyond money. The efforts of our fledgling organization that is populated by a lot of folks who are climbing a second mountain spans a wide range of activities from helping people with the overwhelming task of interacting with public agencies to organizing a crew of ten or twelve volunteers to help a neighbor we never met before move to a new apartment.  I find that these activities give me the same joy that I once found in the practice of medicine. I enjoy being a “doer.” Being active for others is a great reprieve from the cacophony of our times.

 

Steve serves on several community boards, including the board of our local hospital that is an affiliate of Dartmouth Hitchcock Health (D-H). This week Steve asked me to join him in attending a meeting of Partners for Community Wellness, a community involvement activity of the population health arm of D-H. There were more than one hundred people from New Hampshire and Vermont communities that are served by D-H who came together for a luncheon and a two hour discussion about population health in our states. You may be aware of the fact that New Hampshire has one of the highest rates of death from opioid abuse and was identified along with Maine, Vermont, Ohio, Kentucky, and West Virginia as one of the six states that has seen the greatest loss of life expectancy in the 25-64 age group since 2014. We have problems with the social determinants of health. All of the Dartmouth affiliated community hospitals have up-to-date community needs assessments, and are quickly moving to establish a well trained cadre of “community health workers” to do the outreach and case work necessary to begin to address the needs in our communities. Click here if you are interested in the Community Needs Assessment for my local hospital, The New London Hospital. There is also the implementation plan for 2018-2020. Those documents came to life during the conference. 

 

Greg Crowley, the director of Community Partnerships at D-H began the conference by putting up the pie chart demonstrating the origins of poor health that I have often used from the famous paper, “We Can Do Better — Improving the Health of the American People” by Steven Schroeder in the New England Journal in 2007.  That chart is the starting point for any attempt to address the social determinants of health. His presentation was followed by a presentation entitled “Population Health and Community” presented by Sally Kraft, MD, MPH, who is the D-H Vice President for Population Health. Click here to hear Dr. Kraft  talking with Dr. Joanne Conroy, the CEO of D-H about population health. Her presentation at the conference used some case studies to show how the social determinants of health determined the experience of specific patients. The room contained many “lay people” who had joined the effort as “ambassadors” to their communities. Dr. Kraft connected the dots for them between the social determinants of health and the origins of chronic disease. 

 

Dr. Kraft’s presentation was followed by a report of some of the activities of the Ambassador Program. Twenty “Ambassadors” in 14 communities served by D-H had done interviews that revealed that “isolation,” a lack of social ties, and a lack of knowledge of where to turn for help, was an cause of depression and chronic disease for many in our communities. That finding resonated with me and the efforts we were trying to launch with our new little 501c3 organization, The Kearsarge Neighborhood Partnership. 

 

It was a robust program that included the description of a Dartmouth backed “micro funding” program built on the understanding that 40% of Americans would be overwhelmed by an unexpected bill of $400. It’s a fledgling program that has already demonstrated significant successes. The final discussion was advocacy within the political processes and legislatures of New Hampshire and Vermont to rewrite some regulations and create some new programs that will improve the health of the community. The final speaker was Dr. Joanne Conroy, the CEO of Dartmouth Hitchcock Health, who underlined the importance of population health to the future of healthcare in Vermont and New Hampshire. She will insure that the community approaches that have been initiated will continue and become an increasingly important part of the future of D-H’s service to the communities of our region. With over 9000 employees, Dartmouth-Hitchcock is by far the largest employer in the region. It was encouraging to hear its CEO be so articulate about the importance of population health and Dartmouth’s responsibility to address the social determinants of health in the communities it serves.  

 

Following the meeting Steve and I met with Greg Crowley the Director of the Community Partnerships at D-H and members of the team from New London Hospital, including Dr. Gregory Curtis, CMO, Lindsey LaFond, community health worker, and Catherine Bardier, M.S.,Director, Wellness & Population Health. We all agreed that there is much that we can do together to improve the health and the lives of our neighbors. 

 

I sometimes get discouraged with the slow pace of change at the national level. Our most optimistic forecasts must also be realistic. Healthcare reform is a big part of the political discussion, but improvement is a slow process when it works top down. I well remember Don Berwick’s admonition that we should think globally, but act locally. I have discovered that there is much joy in the “second mountain” activity of being a grass roots worker in the effort to bring the benefits of population health to my community. It’s great to know that the benefits that we hope will be available for our neighbors are aligned with the objectives of our area’s dominant system of care. What is happening where you live?

 

It’s Winter For Sure

 

The picture in today’s header is a good representation of the way things were last week, not the way things are now. There is a short story behind today’s picture. My son who is a graphic artist prepares the header for me each week. Last week, I sent him several pictures of ice forming on the lake that were lifted from my neighbor’s drone photography. If you remember, the one we used was almost like abstract art. He also lettered another picture for me that was a more typical, but nevertheless beautiful picture of the lake with a little ice forming around the shore, and beautiful Ragged Mountain on the horizon to the east.

 

My son is a busy guy who somehow finds time to write a new song and put it up on the Internet every week. He has posted a new song once a week for nine years without ever missing a week. That is over 470 songs and 22 hours of music. (Click on the link for a free download of what he thinks are his 23 best songs of Year Nine.) During the week, he employs his graphic art skills by working as a director of digital marketing for a large nonprofit, Per Scholas, that has offices in eleven metropolitan areas and trains low income clients for better jobs in high tech industries. If you click on Per Scholas, you can learn about their impressive work and see what my son does since the website is part of his responsibility. 

 

He usually does a new header for me each week. I give him several pictures and he chooses the best one. Last week he chose the “abstract art” picture, but threw in a second “traditional” option, “just in case.” I am grateful for what he does, so since he had produced two headers, I told him that I would use the “abstract” picture last week, and give him the week off this week by using the other “traditional” header for this week. Who knew that we were going to get a big dump of snow this week, and that the lake would be completely frozen? The picture, which does show a few spots of white and a little bit of ice along the shoreline, is the way things were, and not the way things are now. 

 

I am ok with the way things are. I have trouble with the “in between times.” During the past two weeks we have had ice one day and open water the next. Now it will be all ice, all the time, until mid or late April. In a week or two I will be venturing out on the ice with my auger. My goal for this winter is to finally do some successful ice fishing. At a minimum, I am going to drill a lot of holes! I have two augers. One is a gasoline model that I “inherited” from a fishing buddy who died a couple of years ago that seems almost like a jackhammer to me. The other one is a manual auger that does a nice job if you’ve got the time and energy to crank it. I prefer the manual auger. It seems safer, it’s better exercise, and no noise. 

 

Winter is here for sure. This last storm was interesting in that there was twice as much snow fifty miles to the south of us. Every winter has its interesting moments and sites. Yesterday morning, there were ten huge turkeys in my front yard foraging for food. Enjoying winter to the hilt is like football. You must be on the field, and aware of what is happening around you. I hope that the beauty of winter in your area will be like a magnet that pulls you outdoors for a great adventure this weekend. 

 

Be well, take good care of yourself, let me hear from you often, and don’t let anything keep you from doing the good that you can do every day,

Gene