From the Ground Up OUR STORIES
2013
From the Ground Up our Stories
Introduction
In late December of 2010, Chris McKown and I had the great pleasure of founding a new company called Iora Health. Our mission was bold but quite simple. Instead of making excuses for why our health care system performs so poorly, studying the problem, writing about it, or making incremental changes, we would simply start from scratch and build from the ground up a new practice model that would deliver the sort of care we would want for ourselves and our loved ones. While most others trying to fix health care focused on protocols, processes, designs, branding, and technology, we realized the most important thing we had to get right was the culture of our company itself. If we got the right people to join in our cause, with the right values, and built the right culture, everything else would follow. It is hard to believe it has now been almost three years, and we have over 100 team members serving over 5,000 patients across 3 time zones and multiple sponsors. I am extremely proud of what we have built already. It takes most visitors less than 5 minutes of visiting any of our practices or our Cambridge office affectionately known as “the nest” to realize this is not just lip service or a marginal improvement over typical primary care— but is something completely different. We have the fortune to have visionary and supportive investors, sponsors, and patients—but by far our most important asset is our team. This book is our first attempt to capture in the voices of this team and the patients who we serve what makes our culture so special and unique. What follows is a collection of stories from Iora—recounted by our teams and represented in the words of our patients. It is inspired in no little part by our partner and close friend Tony Hsieh and the Zappo’s Culture book. We have great plans and ambitions to grow, and hope this helps ourselves as well as those considering joining us to understand a bit of what our culture is, why it is so important and special, and how it will help us restore humanity to healthcare. Rushika Fernandopulle Cambridge, Massachusetts November 2013
Our Core Values Lots of companies have values statements. Most sound the same and gather dust on a plaque on the wall or on the pages of an annual report. We have spent a lot of time trying to distill what we care about into a few core values, and hope these are descriptive as well as aspirational, remind us of who we are and will be as a company, and will help us make hard choices as we grow. • Feel Empathy • Bring Creativity • Serve with Humility • Act with Passion • Demonstrate Courage
From the Ground Up · 3
From our patients to our staff, everyone has a story. We’re so grateful to every person who shared their experiences, memories, and thoughts about Iora. A special thank you to Chidimma, Heather, Leigh, Lisa, Gianna, Jennie, Dani, and Zander for their tireless work on this project.
Impact on Patients
When I came to practice at the Culinary Extra Clinic (CEC), I wanted to lead a club devoted to educating patients about diabetes. In June 2012, we had our first CEC Diabetes Club, and in 2013, we began having two clubs each week—one in Spanish and one in English. While we’ve helped many patients improve their hemoglobin A1C measures, one of my most inspiring patients was Ms. J. Born and raised in New Orleans, LA, Ms. J grew up eating food staples like jambalaya, gumbo and cornbread. As a single mother on a budget, she expressed how much she looked forward to 2-for-1 pizza nights. She was encouraged by her health coach Veronica to attend Diabetes Club. When she did,
she was the only patient in attendance. Ms. J was so excited to spend one-on-one time with me to discuss how to better manage her diabetes. She learned that pizza, while it is less expensive than other food choices, is not the healthiest thing that she and her family can eat. As the club wrapped up, Ms. J smiled and said, “I’ve been to other doctors before and they would usually blame me for my poor health. They never tried to help me get better. But you are different. I know you care about me.” It’s incredibly rewarding to have an opportunity to make a difference in patients’ lives. Chidimma, Health Coach, Las Vegas
From the Ground Up · 7
Guess what? Today, a patient got on the achievement board for reducing his hemoglobin A1C from 13+ to 5.1. Impressive! Gianna, Product Manager, Cambridge
8 路 Iora Health
When I visited Culinary Extra Clinic (CEC) last October, a longtime patient with a terminal illness came in to see Dr. Snow to say goodbye. This patient had been with Dr. Snow before she joined Iora. While the patient had not been willing to accept her terminal cancer for a long time, with help from Dr. Snow and the rest of the CEC team, she had recently accepted her situation and was ready to spend her final days in palliative care and closer to her family. However, before she left, she wanted to come back to thank Dr. Snow and say goodbye. While we couldn’t “save” this patient, I was overwhelmed with...love (the only word I can think of) when I saw what a profound impact Dr. Snow and the CEC team had in helping this patient face the hardest part of life in such an accepting and meaningful way.
Who’s icy cold, but warms our patients’ hearts? Buzzy, of course! Buzzy is a four-inch high, vibrating ladybug with tiny icepack wings. An ER physician, who noticed while driving that her hands were numb on the steering wheel, invented Buzzy. Her kids hated the discomfort of shots, so she invented this vibrating cold pack to numb their arms. Buzzy does house calls, has been photographed, videoed, and one patient even featured Buzzy on her Facebook page. Robin, Nurse Innovator, Hanover
We have patients who celebrate their birthdays again because they feel life is worth living. Andrew, Medical Director, Boston
Adam, Manager of Practice Operations, Cambridge
From the Ground Up · 9
“Today, I have been deeply touched by sincere compassion from people who are gifted to understand the highest value of relating human to human. They can heal.� Patient, Hanover
In April , several members of our team met with 125+ stewards and apprentices from the New England Regional Council of Carpenters as a way to “get the word out” about the new practice. Over the course of the evening, we shared a story about one of our beloved patients, the daughter of a carpenter. When we first met her, this young woman was in the ER, overweight, diagnosed with asthma, frequently hospitalized for serious coughing, and suffering from panic attacks, allergies, and sleep issues. She was on a litany of medications—everything from sleep meds to ADHD meds to anti-anxiety meds. More than once, she’d been prescribed drugs that were contraindicated due to her allergies. While these were all serious issues, what struck us most deeply was the fact that she was unable to do the things that were important to her—like attend college classes. Our Physician and Nurse Innovator determined that she’d been incorrectly diagnosed—taking her off 4 of her 10 medications. They listened to her, took time to understand her concerns, and get to know her family. They focused on ways she could achieve her goals, and showed her how diet, exercise, and support could help. The team visited her home to assess the dust problem we suspected might be an issue. In a matter of weeks, she lost ten pounds and reported feeling more in control. This story elicited some light applause and then man in the back of the room raised his hand, saying, “I believe the patient you’re talking about is my daughter.” He went on to describe how the Iora team “saved his daughter’s life”. “Prior physicians had not taken the proper time to understand the situation,” he said, and “their lack of coordination caused grave mistakes”. He expressed how heartbreaking and scary
it was to see his 22 year-old daughter turn blue from coughing attacks that no one could seem to address. He felt that our team “totally turned things around”— providing care in new and unexpected ways. The story blew the crowd away. Suddenly, it became clear: this was not just a union presentation;
this was a group of people who could truly improve lives. Boston Practice
From the Ground Up · 11
One day, one of my patients arrived at the clinic looking for comfort, a shoulder to cry on, or simply someone that could answer her question, “Why did God take my husband?” The patient expressed fear of being lonely and not being able to survive without her companion of 20 years. The care team—health coach and social worker—followed this patient closely. In fact, I provided my cell number for those difficult nights, prayed with her, attended the funeral for additional support, and told the patient to walk in anytime she needed help. A week after her spouse passed away, she visited us again. While she was in the reception area, she met an old friend who was also a patient at the clinic. When our team saw the reunion a light bulb went on. It would be a great idea to have both patients, each widows, provide each other with company and support. They spent a long time sharing their experiences with one another over a snack of almonds and bananas. In fact, they even discussed becoming roommates! When they left the clinic, they both had a heart full of hope for the future. Veronica, Health Coach, Las Vegas
“Thank you both for being smart and sympathetic. Thank you for treating patients like smart grown-ups. You gave me all the information, and let me make my own well-informed decision.” This is just part of an email I received from a patient we’d seen for a quick visit before her vacation to Costa Rica. She was healthy but had come in complaining of possible signs of a urinary tract infection. Her anxiety was clearly out of proportion to her symptoms as she pondered the possibility of getting sick abroad. While her tests were normal, I offered her a prescription for antibiotics just in case she got worse. Her email described how she did not need the antibiotics, but felt secure having them with her. “You’re welcome,” I replied as I wondered: What did I do that was so notable? Like many of the things we do, it was not any dramatic breakthrough. We let her come in for a visit on the afternoon she called in. We listened to her story and paid as much attention to her worry as to her words.
We teamed with her and helped her find a solution to her problem, which was as much about anxiety as it was about infection. Neil, Medical Director, Brooklyn
12 · Iora Health
“The time the staff takes to get to know the patient as a person helps make the medical conversation meld with who I am, and that I am not some faceless illness looking for a robot response.” Patient, Hanover
Iora puts the patient at the center of the healthcare model, which is unique. If patients need a visit, they get it. If they need to skype, email, or call instead, that’s what we’ll do. We even have walking “visits” where I meet a patient over on the college green. It gets the patient active and it’s a great way to bond.
We have a young patient with a complex medical
One of my patients told me she laughs inappropriately at funerals! In that small confession, I learned more about her personality and outlook on life. And it also helped us connect as health coach and patient as we worked together to address her health issues.
and social history. On countless occasions, our social worker, Sarah Tobin, has gone above and beyond to help this particular patient. This patient was recently in a shelter that, due to the organization’s religious beliefs, took away her cell phone and medications. When the patient arrived in the company of another woman from the shelter, Sarah’s suspicions became aroused. Once Sarah asked the shelter representative to leave, the patient was able to share the difficulties of her situation. Sarah then went to the shelter, despite the risks it posed, and retrieved this patient’s belongings. Sarah has now started keeping the patient’s clothing at the clinic, and even doing her laundry. Our patient still has many challenges ahead, but she now knows that has a team to support her every step of the way.
Marcus, Health Coach, Brooklyn
Las Vegas Team
Joel, Medical Director, Hanover
From the Ground Up · 13
Our patient tracking system on my laptop lights up with bold letters “WAITING.” I pull up my patient’s file, toss my stethoscope around my neck and head out to the waiting room to meet Angela. I welcome her with a smile and a handshake. From the yoga studio to the consultation rooms, I give her a guided tour of the facility. I often walk backward because I make a point of making eye contact and not turning my back on my patients. Then, I show her my favorite room—room 10. It’s the largest room, with two walls of windows showcasing the beautiful downtown Brooklyn cityscape. I plug my laptop into the television monitor and gesture for her to sit and join me. I give her a warm introduction to the facility, “Welcome to Collective Primary Care! This is your electronic medical record—there’s no doctor chicken scratch in here! I’m plugging it into this monitor so you can see everything we put in and we can create your medical file together. I’m going to be your health coach, and you’re probably wondering what that is. Here at Collective Primary Care we have a team-based approach. Every patient is assigned a health coach and a provider as your immediate care team so we can get to know you as a person and know what’s going on with you medically. Feel free to reach out to me if there is any way I can support you. Do you have any questions?”
14 · Iora Health
“No, sounds good,” says Angela. “So, what brings you in today?” I ask. “I’m getting headaches. I think I have allergies.” “Ok, what else can we help you with?” I purposely lower my normally boisterous voice to match her quiet demeanor. She lists off some things that concern her and I begin to take her vitals. I hold her hand in mine. I sometimes wonder if this is the most intimate form of touch my patients will receive all day. I place my fingers on her wrist. Hard to find at first, her pulse faintly comes chugging along. Bom. Bom. Bom. Her life force, I can feel it in my hands. I look at the clock, about to start time and count. The little hand reaches the 12, and I start, 1, 2, 3… I look back over at Angela. She has wilted like old lettuce in the fridge. Completely. 4, 5… I see tears drip down beneath her thick blackrimmed glasses, her body shaking. I immediately stop. I place my hand on her shoulder and quietly say, “We don’t have to do this right now.” We walk back to the table and chairs and I ask, “What’s going on?” “I’m worried about Harper, my daughter,” says Angela. We aren’t getting along. I think we need to go to therapy…I’m so scared she’s going to get into drugs.”
“Why do you think that?” I ask. “She’s an eleven year-old girl. I’d think we would have to worry about her kissing first!” “My sister…she’s an addict. And now she’s homeless somewhere on the streets. I’m so scared Harper is going to turn out like her unless I do something now,” says Angela. “We have a therapist here on staff, would you like me to bring her in now and we can all talk for a little?” She nodded her head profusely with a bunched up ball of tissues in front of her face. How could we treat Angela for her headaches when there are so many other components at play? This is how the patient leads the team at Collective Primary Care. As the health coach on that team, I am an information gatherer, supporter, and connector of patients to people, resources, information, and knowledge. I was able to take care of her in the moment, and now Angela is taking care of herself by utilizing our resources and calling upon us when she needs support.
There is so much more to taking care of someone than treatment plans and health goals. There is something to be said about being present with someone; seeing and hearing each patient as a whole person with a unique story, a life, love, and passion. It is my honor to meet the patient in the present to make steps toward achieving happiness and health for lifetime. Leigh, Health Coach, Brooklyn
“Words can not express how happy I am with the care and staff. I don’t come to a ‘clinic’—I come to see family.” Patient, Las Vegas
From the Ground Up · 15
“It’s great to be encouraged and to become aware that life is precious. Thank you for reminding me to remain true to my promise to be mindful about life on a daily basis.” Patient, Dartmouth Health Coaching
By the time one of my patients came into our clinic, he knew something was wrong. During the visit, his blood sugar was 456 and his A1C was 11.7. Both these numbers meant he had diabetes. His doctor started him on insulin, he worked with a nutritionist, and met with his health coach every week. One month later, his fasting sugars were consistently in the 130–150 range with insulin. Two months later, his blood sugars were consistently in the 80–90s with spikes after meals to 130. He started lowering his insulin. And four months later, he has lost 45 pounds, takes zero insulin, and his fasting blood sugar readings are in the 90s. Without looking at numbers, you can tell he feels great. It’s amazing to see what this patient was able to achieve with the support of his healthcare team. Tyler, Health Coach, Hanover
The other day, a gentleman who appeared to be in great distress walked into the Culinary Extra Clinic. As he approached the front desk, I asked him how he was doing, and he replied that he was not good. I asked him what was causing him trouble, and he said he had received a voicemail that had lead him to believe he was no longer eligible for benefits. He was very confused and upset and when I asked what I could do to help, he responded with “I could use a hug.” So I walked over to him and gave him a hug! He said I made his day. Then I spoke with Sarah, our social worker, about the gentleman’s emotional state. Sarah was on her way to our quarterly Patient Advisory Board, but she took the time to talk to the patient. She ended up sitting with him for a long time even though she was running very late to the meeting. By the time the visit was over, she was able to resolve some of the issues that were upsetting him and the patient left with happy tears and a smile on his face. Karina, Operations Coordinator, Las Vegas
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Subject line:
I touched my… Email:
…toes today! True, I had to bend my knees a little to do it, but still, I haven’t been down there in years. I’m the last guy you’d ever expect to see at a yoga class. But after my doc from Collective Primary Care sent me to see Marcus for a yoga consultation about back pain, something clicked. After years of telling anybody who would listen about what was wrong with America’s healthcare system, I’ve found a practice centered around wellness rather than sickness. Yoga works for me—I’m willing to give it a go! Patient, Brooklyn
Thought you’d get a kick out of that. Your student, R.B. Patient, Brooklyn
From the Ground Up · 17
I’ll never forget one of my very first patient visits. It started as a fairly routine visit, but at the end, the patient teared up and said, “I’ve never actually felt heard at the doctor’s office before, this is so different.” It was so moving and it reminded me that even if you don’t feel you’re doing anything, the power of listening and being present can be healing to patients. Tara, Health Coach, Brooklyn
“They help to coordinate everything when I’m at work. The health coach is more like a health angel—there for us 24/ 7.” Patient, Las Vegas
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I was at Culinary Extra Clinic about to visit with a patient when a few health coaches gathered outside the exam room with balloons. We entered into the room singing happy birthday to one of the patients because he had turned 89 that day. He was speechless and could not stop smiling. Hannah, Business Development & Operations Analyst, Cambridge
I was shadowing health coaches and doctors as part of my role as software product manager for our collaborative care platform. A patient came in for her first visit, visibly flustered. The health coach was gathering information, asking that patient questions about her medical background, and social and family history. The patient kept apologizing for being so upset, explaining that she had just come from work, where she had an unpleasant encounter with a verbally abusive co-worker. As the patient revealed more about her medical history, it became clear that her family, work, and personal life were affecting her medical status. I sat silently as I learned of this woman’s courage in spite of many setbacks: leaving home at 16, enduring an abusive husband, a messy divorce, a foreclosure, and now having an adult son who was in prison serving a life sentence. A gentle knock on the door was followed by Dr. Andrew Schutzbank, who introduced himself. He sat right next to the patient, only occasionally glancing at the computer screen, turning his body fully towards her. She again apologized for being flustered, and made a several self-deprecating remarks while describing a recent fainting episode. At this point, Andrew stopped, placed his hand gently atop her hand, and asked “Who taught you to talk to yourself like that?” He waited for a response. I watched as the patient’s body uncoiled. She paused and breathed in, realizing that he was waiting for an answer. Time seemed to stop. I saw an expression of surprise and realization move across her face while
Andrew patiently waited for her response. After a few moments, Andrew simply smiled and said: “That’s something we’re going to work on together here.” People have a natural rhythm that has gone ignored by the regular quickened pace of computer technology and healthcare efficiency experts.
When we design care to allow for moments of silence and reflection, we are restoring the natural rhythm of humanity to healthcare. Jess, Principal Product Manager, Cambridge
From the Ground Up · 19
“I don’t feel pressured to take a bunch of tests, I don’t sit in a waiting room for hours, I don’t feel rushed, dismissed, patronized, unimportant or exploited. I am still getting used to not having to fight for an appointment, a prescription,or to feel visible in some facility. As soon as I walk in, I feel like a respected customer with choice and dignity. And that makes me feel like my health is important, and encourages me to take the best care I can of myself.” Patient, Brooklyn
My friends ask me who I am texting. I tell them that I’m texting my health coach, getting my goals together. Patient, Boston Practice
One of our patients, a carpenter, was prepping to become a first-time dad. He and his girlfriend were unable to afford prenatal/parenting classes, but they wanted to start their family off on the right foot. Our team met with them and based on the success of that first meeting, set up an ongoing schedule for providing additional prenatal support. It was such a success that we’re now talking about creating a discussion and support group for new dads! Zander, Chief Operating Officer, Cambridge
When I first walked in Collective Primary Care’s doors, I weighed 212 pounds and my blood pressure was 135/86. I was just biking through Battery Park and there was an event going on for free blood pressure readings and mine was like 96/71. I’m pretty sure I’ve never had a reading below 100 in my life! Am I fitter now than I was in my 20s? It’s entirely possible. Thanks again. For everything.
Not long after we opened, I began working with a patient named Ms. B. She was young, healthy, and had just moved with her husband to Hanover for their teaching jobs. But right before the semester started, Ms. B was diagnosed with a rare form of cancer. During the whirlwind of imaging, biopsies, visits with specialists, surgery, then chemotherapy, Ms. B came to us frequently for support. Since they were new to town and their families were far away, their social resources were limited. I had the privilege of taking Ms. B to a couple of her chemo infusions, and later even met her parents when they visited the area for the holidays. Ms. B’s personal resiliency and trust in our practice was powerful to witness. Kim, Health Coach, Hanover
Patient, Brooklyn
From the Ground Up · 21
Working in a healthcare setting every day, it can be easy to become complacent about the standard procedure of scheduling patient visits. But sometimes there are moments when you realize just how much it matters. A few months ago, a health coach asked me to call a patient to schedule a same-day visit with Dr. Laura Duncan. However, the patient wanted a direct referral to see a specialist instead of coming to Dartmouth Health Connect to see her Primary Care Physician. When I spoke to the patient, she was hesitant to make the appointment because she felt no one here could help.
I quickly realized that this was a phone call where I needed to listen as much with my heart as with my ears.
22 · Iora Health
The conversation evolved from a simple appointment to a true dialogue of the pros and cons of a visit from the patient’s own stand point. By the end of the call, the patient decided to accept the appointment. Following the visit, the patient’s health coach sent a “task” comment saying the patient was “super thankful” that I had called, listened, and made the appointment happen. In my role at Dartmouth Health Connect, I don’t get to have one-to-one patient contact as everyone else does. But in that moment and in others, I really feel that sense of helping. Maybe appointment scheduling isn’t merely “operational” as we sometimes think. I still keep that “task” comment on my task list. It’s a reminder that fills me with inspiration and keeps me focused on the care that patients need and deserve. And on the care I want to provide. Wendy, Office Coordinator, Hanover
At Dartmouth Health Connect , we work in a “Culture of Yes,” which means we do whatever it takes to help our patients get back on their feet. For example, we recently did a home visit to re-evaluate a patient with a virus and draw some necessary blood work. After a successful course of treatment, the patient emailed, “I have been vertical for the last 6 hours, thanks to you! For 5 days I lay flat on my back, like Sleeping Beauty, while weeds and vines grew up around my house. Today I am almost ready to take them on.” Laura, Physician, Hanover
“I love the fact that I can get any issue addressed, small or large, without worrying about the cost or scheduling. It is a huge step in creating wellness and not just managing urgent health issues. I also love that I have a point of contact in my health coach who knows my history, can access a tremendous number of resources to help me with whatever issues I am having, and she knows what my insurance will cover. That
In April , Maya Angelou was interviewed by Oprah on her birthday. Oprah asked her what she thought of growing older and Maya responded, “I’ve learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel.” Marcus, Health Coach, Brooklyn
is major as determining coverage is one of the most painful exercises in healthcare. Having good quality, proactive, accessible healthcare should be everyone’s right. Sadly, it is rare and I feel fortunate. Thank you!” Patient, Brooklyn
From the Ground Up · 23
One of our patients came into the practice crying. Her 14-year-old son, Danny, was over 300 pounds. He had already been hospitalized for pre-diabetes, was on metformin and had elevated A1Cs. His mother didn’t know what to do, he was a 14-year-old kid and his health problems were causing him difficulty at school and with his peers. Culinary Extra Clinic treats patients over 18 but when our team understood the situation, we got in touch with the Culinary Health Fund to get special permission to see him as a patient. Getting him in the door was the first hurdle—but once he had a care team, the real work began. I started working with Danny to see if we could help him lose some weight and improve his overall health. I realized he had poor male role models in his life, his brother was into drugs and gang activity and his dad wasn’t that involved. While he needed a health coach, he really needed a role model and a friend. I asked Alex, a fellow health coach, if he could help me get Danny active as he has been great at helping
patients get motivated and empowered to lose weight. On Saturday or Sunday, the three of us would go to the gym together. Danny didn’t know his way around a gym—so we showed him the ropes, spending time with him and teaching him how to work out through strength and cross training. Through those weekend visits and hard work, he lost 47 pounds. It can be hard to understand what a huge deal that is—one day I had him carry 47 pounds around the clinic to put his success into perspective. He couldn’t even carry that amount of weight in his arms. Since he has lost the weight, he is no longer on medication for diabetes and his A1C levels have come down. There are new and different challenges now that he is growing up. People in his community are testing the waters, doing drugs and getting into trouble. We are coming up with new ways to keep him engaged and offer a safe space for him to seek advice and talk about what is going on in his life. Things like tutoring help to improve his grades and encouraging him to play sports to keep him active are goals we continue to work on.
Working with a younger patient has been about finding the balance between being the role model, friend and health coach. It is a mentor relationship. Danny looks up to Alex and me. We want to be people he looks up to. People he trusts. Dennis, Health Coach, Las Vegas
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A carpenter (and healthcare skeptic) came into the clinic one day with his wife, feeling crummy. At the end of the visit, his wife booked an appointment for herself and their 19 year-old daughter for the following day. Both women came in for wellness exams, elevated Body Mass Indexes, allergies, and general dissatisfaction with their health. After an evaluation, our team suggested several diet and lifestyle changes. We offered to make a home visit during which two of our health coaches would help with goal setting, label reading, and cooking. At their house, the family listened intently to the label reading guidelines and then attacked their pantry to evaluate their foods! A short time later, mom and daughter reported back, each having lost 4 pounds, and the carpenter confessed that he is feeling a little better and is going to give the new program 6 months!
“Healthcare professionals with a new mindset who are not slaves to a failing system that ignores our humanity.” Patient, Hanover
“I like that I have the time to deal with all of my health issues.” Patient, Boston
“It was a relief to be listened to. It was actually extraordinary.” Patient, Brooklyn
Boston Practice
From the Ground Up · 25
The Freelancer’s clinic isn’t just practicing medicine—it’s practicing wellness. Their approach is that the road to good health is not traveled with just a prescription as a map. The road must be traveled with a guide, with management, and with a companion. I’ve walked alone for so long. I’m tired and worn out, but I am not walking alone any more. Patient, Brooklyn
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“I cannot thank you enough for restoring my faith in what modern medicine can be. The staff really took the time to listen and fully explore my options. Having the records up on the screen made me feel like I have a say in my healthcare rather than like the doctor is writing some secret scrawl about me that I can’t see.” Patient, Brooklyn
Patients’ minds and bodies are so linked. Take Ms. L for example. When she came to us, she wasn’t taking care of herself and she rarely left her house. We found out that she had been phased out of her career and had recently lost a parent. After working with us for three sessions on her mental and physical health, Ms. L regained the strength she needed to apply for unemployment, reach out to family and friends, and begin focusing on her wellbeing. Charlotte, Social Worker, Brooklyn
One of our patients, a middle-aged woman, was struggling with her weight and getting her diabetes under control. Between her job and family responsibilities, she’s been having trouble losing weight and getting to the gym. She met with her Iora health coach and doctor, who introduced her to Hammer Time, high-energy fitness classes designed specifically for patients covered by the New England Regional Council of Carpenters. Our patient comes to Hammer Time every week, and now brings her son to class. She has started walking daily and continues to check in with her health coach every two weeks by phone or text message. She says this is the one thing she has to take care of herself. Boston Practice
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They say that chicken soup can help cure a cold. As a health coach, I’m actually beginning to think this might be true! I found this out from a patient in her early thirties, who was home recovering from a serious upper respiratory infection after spending three days in the hospital. When we arrived for a home visit soon after her discharge, we found her noticeably weak and tired. It became apparent that while she had been able to rest, she hadn’t been able to nourish herself in a way that would promote healing. Though it was already mid-afternoon, she hadn’t yet eaten that day. I headed into the kitchen and looked through cupboards and the fridge. I added some chicken, leeks, carrots and brussel sprouts to a pot and put it on a burner. By the time we left, she was sitting on her sofa eating a steaming bowl of soup. Well fed and set with a follow-up plan for her care, our patient expressed her gratitude for the personal and individualized support she had received. Soon after, she recovered from her illness and was back at work. Making chicken soup is only one of the ways our team reaches out to provide patient-centered care. But, I can safely say that it was probably the most delicious way.
One of the most powerful moments at Iora happened on my first day on the job as a health coach. While I had high expectations, I knew “it couldn’t be as cool as the way Rushika described.” Well—my mind was blown during my very first patient visit. A diabetic patient had missed a few appointments and Diabetes Club classes. He professed his stubbornness, saying, “I don’t really listen to anyone,” and went on to describe how he came up with his own methodology for when and how to take his medications (that did not align with doctor’s instructions). He then shared that he loved the Clinic, and that without the team and in particular, his health coach—whom he called a “savior”—he did not know where he would be today. He explained he was missing Diabetes Club meetings because his son’s football games were at the same time. After missing out on so much due to health issues and other challenges, he finally felt well enough to attend games, and wanted to “be there” for his son. All I could think was “Wow.” We spent 45 minutes chatting, and I was able to immediately see the power of the health coach interactions and the Iora model. Even better—I was able to really feel the impact that our wonderful team was making. My decision to join Iora was immediately confirmed.
Lisa, Health Coach, Hanover
Duncan, Senior Director of Practice Operations, Cambridge
From the Ground Up · 29
Impact on Ourselves
Ever since I started working at the Culinary Extra Clinic, I’d been talking about my beloved Jerry who lost his life to Long QT Syndrome, a rare inherited heart condition. I wish I could have seen the symptoms, as he had them all. On February 4, 2013, I was invited to attend the Heart Awareness Red Dress event in New York City in appreciation for the volunteer work I have done for the Sudden Arrhythmia Death Syndrome (SADS) organization. You see, I translate medical documents for the Hispanic population. If one person becomes aware of symptoms by reading one of my translations
and seeks medical care I would consider my job well done. Although my team did not accompany me to New York, they were with me every step of the way. They cry with me when I hurt, and they celebrate my accomplishments. Not only did my co-workers cover my shift and tasks while I was away, they dressed in red to show their support. I may have lost my best friend, but life has given me a new family. I thank God for blessing me with them. I feel honored and privileged to be a part of this loving group. Veronica, Health Coach, Las Vegas
From the Ground Up · 31
Two years and eighty-five days into my internal medicine residency, I realized why I didn’t sleep well at night. Up until that day, I’d chalked it up to the fact that I was working 30-hour shifts every four days or that my wife (and co-resident) was often missing from our bed on the few nights that I was home. I figured that once I completed my three years of training, life—and sleep—might return to normal. But the real reason came to me—as it does, perhaps, for so many in my predicament—while driving down the Las Vegas Strip. I just didn’t believe in what I was doing. I’d come to residency awash in idealism, ready to save the nation through expanded primary care services for all and meaningful implementation of the Affordable Care Act. I figured that my core belief system, values, and skill set in medicine, policy, and management would keep me focused on the goal of transforming people’s lives through phenomenal medical care. Yet, everywhere I looked, that kind of phenomenal care was nowhere to be found. Sure, I knew incredible physicians and nurses and we had access to the latest
technologies and innovations. But truly phenomenal care—the kind that envelops a patient and nurtures him toward better health and a better quality of life? It just didn’t exist. In retrospect, it’s funny that I had this (sober) realization on the Strip. I had to hit rock bottom to realize it, but what I encountered in Vegas was an oasis of hope. This driven, energetic, passionate team that was solely focused on healthcare transformation was unlike anything I’d seen. They were able to effectively impact the sickest of the sick and help those who need it the most. Its mere existence, for someone as prematurely jaded and fatigued as me, was simply stunning. Over the course of the next few days and weeks, I took care of patients. I worked with amazing partners to solve problems, both big and small. I laughed often. I woke up energized to go to work every day. And at night? I slept. Through the night. Without interruption. But I wasn’t surprised. After all, I was finally doing something in which I could believe.
That is how Iora restored humanity —at least to me. Ali, Physician & Clinical Innovator, Cambridge
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From the Ground Up 路 33
On my fourth day at Iora, I went to Brooklyn so I could visit a practice. Following huddle, we went out into the lobby to brainstorm and role play different scenarios for various service experiences. In my previous job, I worked on many healthcare service design projects, and we often encouraged our clients to use role-playing and scenarios to prototype a service experience. As I sat in the midst of the Brooklyn team, I found myself thinking, “This is it. This is actually happening, right here, in front of me—a team of healthcare practitioners is completely focused on how to deliver the best possible experience to their patients. And I am part of it.”
On April 20, 2013, my CEC colleagues and I participated in the MS walk in honor of our wonderful patient Ms. J. and on behalf of many others living with MS. I’ve watched Ms. J fight bravely through multiple difficulties and the daily fear of the unknown. Through it all, she personifies determination and courage. She wears a beautiful smile on her face and her enduring positive attitude guides her through the day. She never gives up. She never quits. We walked because we know that a small group of people can change the world one step at a time. Veronica, Health Coach, Las Vegas
Gianna, Product Manager, Cambridge
Whenever we think about compromising around software, our developers stick up for patients. They hold us to our principles because they have been in the practices and know the patients. Andrew, Medical Director, Boston
34 · Iora Health
“I love walking in and being greeted by my name. Just knowing that I can call the doctor if I’m having issues is a relief and makes me feel better. The doctors and staff really care about us! Which means better results!” “New way of life, this clinic. I feel like it’s family. I am glad to be here. Thank you.” Patients, Las Vegas
“I accomplished a huge goal. I quit smoking. Anytime I need to be seen, I can always call and they always take care of me. They take the time to call me to see how things are going.” Patient, Las Vegas
Creativity: The Iora on the Christmas cookie—yay! Alexis, Manager of Practice Operations, Cambridge
Many of the people we’ve hired have told me that they made previous career choices—whether working in hospitals or teaching school—because they thought it would be a great way to help others. But those jobs always had arcane rules, excessive bureaucracy, and infinite roadblocks that prevented them from doing the right thing for the people they were supposed to care for. Whether during an interview or after working at Iora for several months, I often hear that they are so energized by this opportunity to just do the right thing for other human beings. Zander, Chief Operating Officer, Cambridge
36 · Iora Health
One day , I walked over to the Culinary Union Event Center, where I lead yoga classes, feeling extremely discouraged. I hated to admit it, but I hoped that no patients would show up for yoga class so that I could have a few minutes to connect with my life coach before heading back to the clinic. As I walked in, I saw two patients who regularly attend yoga class, a third patient who hadn’t attended for several months, and a fourth patient who was new to the yoga class. When she gave me her name and signed the waiver, I was humbled. I realized she had recently undergone a heart transplant. In fact, she had been on our crisis list and had been discussed extensively during our huddles. At that moment, reality hit and I realized that regardless of what is happening with me personally or professionally, I have an opportunity—a commitment— to serve our patients. While I was reading the meditation for the day, a text came from my life coach. She had recently watched a video on YouTube about a veteran who had undergone a major physical, mental, and spiritual transformation thanks to yoga and she wanted to me to know that what I do makes a difference. My eyes welled with tears. Class concluded, my ladies rose from their respective peaceful places and two of the regulars went to lunch together. They became friends as a result of their regular attendance at yoga class and they are now invested in one another’s lives. Seeing the fellow patients who went to lunch together, meeting the lady who underwent major surgery, and receiving the text from my life coach all worked together to change my heart.
I thought: My heart needed to undergo a transplant. God saw fit for it to happen on my mat and
as I was teaching others, I was taught something: humility and gratitude. Chidimma, Health Coach, Las Vegas
From the Ground Up · 37
“All right, everyone let’s get up out of our chairs—it’s time to make a human knot and untangle ourselves!” Groans and smiles all around the conference table. We look at each other knowingly, wondering if this will be the time we actually succeed. The ten of us have tried this twice before and ended up in a tangle of arms and legs, no resolution to the puzzle, no apparent way to untie ourselves. Our “Huddle” time morning planning meeting and the team building exercises that precede it every day—whether it be untying a people knot, listening to a Mary Oliver poem, marching around the office together during 4th of July week waving flags and creating our own little parade—illustrate for me what makes being part of the Iora team special. Our priority
38 · Iora Health
is to always deliver the best, most cohesive, patientcentered care as demonstrated by the emphasis put on coordinating care between physicians, health coaches, and nurses each and every day. But this hard work happens in the context of a fun, stimulating, learningfilled environment full of innovation and joy. And just in case anybody’s wondering, the third time with the human knot was a charm. We untangled ourselves like a team of pros and took charge of the rest of the day in the clinic, too, continuing to work to untie human knots at every turn. Lisa, Health Coach, Hanover
“I cannot say ‘thank you’ enough to Dr. Lazar and Kim Hall for being such a supportive team. I feel that my health is not my journey alone but one where I have guides to keep me on the path of wellness. My experience has been well beyond my expectations.” Patient, Hanover
Last night I heard myself say, “You know, if I don’t eat enough vegetables I just don’t feel that good.” Now that is something I would not have said before I came to work at Collective Primary Care and fell under the spell of Giovanna. Generally, I ate good quality food in moderation but definitely did not make significant room on my plate for vegetables. Then there came that first day that I smelled the scents of her cooking. I discovered that vegetables can taste amazingly good and that I can feel better with a diet that is rich in them. Giovanna is so genuine in her love of good food, so dedicated to delivering her message in a kind and compassionate way, and so skilled in her cooking that perhaps I had no choice but to be moved as I have been. Popeye tried to convince me about spinach and he failed. Giovanna succeeded in changing my life and I am so glad she did. Arthur, Health Coach, Brooklyn
My team inspired and supported me without
“I like how validating it is. My coach remembers things I told him months ago, so he’s able to point out how much growth I’ve made that I’m not even aware of.” Patient, Dartmouth Health Coaching
question during the start-up of the Boston Practice in making sure time was taken to make me feel more confident in my computer skills. I had found that to be the biggest challenge in starting in this new journey. To this day I am so comfortable with asking any of my team members for any help—with any questions I may have. Thank you Team Boston, if it wasn’t for your support I probably would not still be a member of this awesome team. I do love my new career! Health Coach, Boston Practice
40 · Iora Health
Things people are saying around CPC: “That new guy is really hip!” Arthur “Zander made me a ‘bonefied’ offer for joining CPC!” New guy “The new guy makes life so easy—just tells me just the bare bones of what’s going on in the office when I’m busy acupunturing it up in the yoga room!” Steve “That new guy cracks me up, he’s so humerus!” Marcus
Nowadays software developers collaborate with their stakeholders, but at Iora, I’ve been privileged to go beyond that and make the rounds with health coaches and MDs in our far-flung practices. I’ve seen colds remedied, families counseled, and double-amputees get care and a pep talk. Seeing this, you remember that the newest things such as software are supporting the oldest traditions of healing and support.
When Hurricane Sandy hit, Neil sent us a message saying “guys, don’t worry about work, if you can, go volunteer somewhere and take care of your families. I hope everyone is safe.” I was very touched by that. Giovanna, Director of Patient Engagement, Brooklyn
John, Chief Software Architect, Cambridge
From the Ground Up · 41
When I finished my phlebotomy certification, I applied everywhere and I got a call from one place: Iora Health. After I had my first phone interview, I was so excited that I had a shot. When I got hired, I was over the moon! I had no experience coming into this field
42 路 Iora Health
but I was received so enthusiastically, which makes me want to work harder. Iora Health gave me a chance and I feel that I owe it to the company to devote myself to this job. I love it! Leah, Phlebotomist/Administrative Assistant, Brooklyn
A great moment? When our Boston practice team realized that they did not have to worry about being taken to task for taking initiative and doing whatever it takes to care for patients. After many years of being told, “No, you can’t do that,” they began to believe that the answer could be “Yes, you can try that.” Gianna, Product Manager, Cambridge
From the Ground Up · 43
I have had the great opportunity to get to know a special patient, Ms. C. She’s a double-amputee who has struggled with diabetes for 20+ years. Ms. C. possesses a great spirit and presses on through life, in spite of its challenges. As an example, to get to her dialysis treatments three times each week, Ms. C. takes a bus that drops her off three blocks away. Once, Ms. C. had a dialysis treatment and two doctor’s appointments on the same day, making it necessary for her to take the bus to each location. When she arrived at her last location, which was the Culinary Extra Clinic, we offered to pay for a taxicab so that she could get home in time to have dinner with her family. She refused the taxi ride and even went to the pharmacy after her appointment. As I left the clinic that day at 5:00 p.m., she was just leaving the pharmacy. When I arrived home after 20 minutes of driving, I thought of how she was likely still on the bus, on her way back home. My mind wandered to the things we take for granted. She is truly an inspiration. Jeannette, Health Coach, Las Vegas
44 · Iora Health
One of the things about being a jazz musician is, you’re always wondering, how can I contribute to something that’s as great as all the greats that came before, but still different and awesome? What would that be like? Now…I’ve been programming computers for years…every day I go in, I get some coffee, I sit down, I start typing and things show up on the screen, I get more coffee…and I love it! And every once in a while, I stop and ask myself, “what exactly am I contributing to?” And for the past year at Iora, when I’ve done this, this whole question about wondering what it would be like to be part of something really amazing and have all these diverse opinions, but have everybody on the same page and pushing toward the same goal…that question is totally answered in being part of Iora: It’s pretty awesome. Dave, Software Engineer, Cambridge
“I like how much everyone cares to keep you informed and how helpful they are. They make you feel in control.” “Convenient personal care made me feel comfortable and like I was important.” “All of them. So resourceful and kind, love all the people!” Patients, Boston
Marcus had seen one of my patients regarding upper back pain. After the appointment, Marcus sent me a beautiful plan with links and photos of yoga positions that help relieve tension. One was using the yoga long strap in a crisscross fashion to pull your shoulders back. I was a bit confused as to how to put it on so Marcus showed me in the waiting room. Two patients walked in and peered over at us with curiosity. “That looks like it feels good,” one patient remarked. “Would you like me to teach you?” I exclaimed. I felt so proud that I was able to learn a wellness technique and spread the good gospel to others that were excited to learn. Marcus was smiling from ear to ear like a proud dad. Leigh, Health Coach, Brooklyn
Last board meeting when I was getting the
“Just being accountable to someone who understands, is educated in that particular area, and is non-judgmental is very helpful.” Patient, Dartmouth Health Coaching
46 · Iora Health
board binders together to be shipped out, I had been working on them all day and run into a bunch of snags. I was scrambling to get them done to meet the Fed Ex drop-off deadline when Scott, Rushika, Zander, Andrew, and Nicola wandered in and insisted on helping. Together, we got them done in less then ten minutes. Where else would you find executive team members and docs willing to do that? Danielle, Assistant, Finance & Administration, Cambridge
My patient Max’s decades of struggle with diabetes were informed, at least in part, by the care and attention he offered so generously to others, but too infrequently to himself. One day Max, his coach, and I had a long discussion on this theme. It was a heartfelt encounter on all sides. To bring home the point, at the end of the visit, I scribbled a mock-prescription on Iora stationery: “Focus on your own needs!” Three weeks later, after an especially long day, an email arrived which brought me literally to tears. It was from Max, with a photo attached of that same prescription, now enclosed in a wooden frame. And with it the following explanatory text: “Here is the photo of the ‘prescription for life’ that you gave me. The prescription is in the frame that I received from Dartmouth for 10 years of service, which has been empty for 2 years since I wanted to find something that was suitable and your note was the perfect item. The frame is constructed from wood from the 2nd College Grant. The prescription is in my office so that I can remind myself of its importance every time I see it. Thank you for everything!” And now I keep his photo in close sight as well.
Thank you, Max, for reminding me what is possible, in all directions, when we meet each other openly and heartfully. Joel, Medical Director, Hanover
From the Ground Up · 47
I once had a challenging experience with a patient who was very upset, frustrated, and scared. When she started screaming in the room, Katherine knocked on the door to see if everything was ok. Then Neil came in and so gently and humbly tried to clarify what he thought next steps would be for this patient so that she would feel heard. After the appointment, Giovanna and Nandi gave me big hugs. Jen and Tara stayed late after work with me to make sure I was feeling ok. I felt like I had a true partners and champions by my side even during the darkest times. Leigh, Health Coach, Brooklyn
48 · Iora Health
In my first ten minutes on my first day, a bell rang in the office. At first I thought it was some sort of emergency. But then everyone started gathering around Paul congratulating him and asking him to “tell us how it happened.” Paul went on to recount the details of how he proposed to his fiancée the night before. It was then I realized that I had joined a very unique group. I was not just a member of the “staff” but a member of team that cared for and celebrated each other. Hannah, Business Development and Operations Analyst, Cambridge
Closing Thoughts
Every day, at practices around the country, we have several hundred interactions with patients—by phone and email, in group visits and in private conversations—where our objective is to help each patient define and reach their goals, whatever they may be. We believe that we are on a journey to create a sustainable model of care delivery that puts each patient’s wishes at the center of the conversation. We do this by building strong relationships where honest, caring conversations happen between patients and care team members, and also between our staff and leaders at the “sponsor” organizations who make this work possible, amongst individual staff members, and between our teams and respected providers in each community we serve. This collection of stories is an effort to shine a light on those relationships, and to share reflections on the journey in the words of many. If we are achieving, in some small way, our aspiration of restoring humanity to healthcare, it is because team members in every role are making thousands of small decisions every day that provide remarkable service to patients, to the community, to each other. Our software development team focuses on creating “MVP” or “minimum viable product”—the smallest, quickest thing we can create that will add value to a user’s experience. We also think about “MDP” or “minimum delightful product”—the smallest, quickest thing we can create that will truly delight someone. As we gathered these contributions from across the Iora Health family we were struck by the passion for service and the commitment to delight that runs deep. We hope that we have done right by all of our colleagues and patients in putting together this collection of stories for the first time— our MVP attempt, or MDP, if you like—at capturing some of what makes Iora Health a special place. We have much still to learn and to improve upon, but perhaps this collection will remind us all—on our most challenging days—of the journey we set out on together, and will provide a glimpse into our culture for those curious to learn more. Gianna Marzilli Ericson, Product Manager Zander Packard, Chief Operating Officer From the Ground Up · 49
Iora is… a million tiny moments each day—from hundreds
of thousands of lines of code, to a phone call from a worried patient answered in the night.
November 2013 • Ashland, MA
IORA TEAM members
Culinary Extra Clinic, Las Vegas, NV
54 路 Iora Health
Karina Bocker
Operations Coordinator
Dania Correa
Operations Coordinator
Veronica Fernandez
Health Coach
Glendalee Jackson
Health Coach
Scott Jacobson
Physician
Veronica Jaime
Health Coach
Dennis Leon
Health Coach
Yanell Nava
Assistant Nurse Innovator
Barbara Nunez
Health Coach
Chidimma Ozor
Health Coach
Carolina Pavese
Director, Clinical Operations Las Vegas
Alejandro Preciado
Health Coach
Jeannette Salabarria
Health Coach
Mayra Sanchez
Health Coach
Alejandra Sandoval
Operations Coordinator
Evangelina Snow
Physician
Anjali Taneja
Medical Director
Sarah Tobin
Social Worker
Collective Primary Care, Brooklyn & Manhattan, NY Giovanna Akins
Director of Patient Engagement
Arthur Aronson
Health Coach
Nirmalya Banerjee
Operations & Clinical Assistant
Jennifer Benetato
Social Worker / Health Coach
Marcus Berardino
Health Coach
Nandi Charles
Health Coach
Jennifer Fuller
Health Coach
Stephen Dahmer
Physician
Charlotte Elkin
Social Worker
Leah Fasano
Phlebotomist / Administrative Assistant
David Gellis
Physician
C. Leigh Goldsmith
Health Coach
Steve Guidi
Acupuncturist
Pete Hagan
Health Coach
Stacey Keith
Health Coach
Hillary Lopes
Health Coach
Katherine Marx
Nurse Practitioner
Stephanie McCoy
Nurse Innovator
Tara McCoy
Health Coach
Ronica Mukerjee
Nurse Practitioner
Melissa Price
Nurse Innovator
Neil Patel
Medical Director
Laura Teti
Health Coach
Heiraland Williams
Operations & Clinical Assistant
Dartmouth Health Coaching, Hanover, NH Nancy Duhaime
Health Coach
Jennifer Letendre
Health Coach
David Peckinpaugh
Health Coach
Dartmouth Health Connect, Hanover, NH Lisa Cadow
Health Coach
Laura Duncan
Physician
Kim Hall
Health Coach
Tyler Hanna
Health Coach
Wendy Jillson
Operations Coordinator
Joel Lazar
Medical Director
DHC Logo: Green: c80 m15 y75 k35 • PMS 555c Blue: c63 m18 y19 k0 • PMS 7458c Gray: c0 m0 y0 k68 • PMS 424c
Dartmouth: Museo Slab 500
Nurse Innovator
PCP: Museo Sans 700
Amanda Rice
Behavioral Health Specialist
Chris Spelman
Health Coach & Practice Operations Manager
Gabe Wegner
Health Coach
Elizabeth Wolfe
Physician
Health Connect: Museo Robin Rice-Voigt Sans 700 Dartmouth/Iora: Museo Sans 100
Iora Health, Boston, MA Heather Carroll
Social Worker
Heather Hardy
Health Coach
Mike Jeudy
Health Coach
Ravi Kavasery
Physician
Brendalys Rosario
Health Coach
Jennifer Taylor Landry
Health Coach
Wendy Storch
Nurse Innovator
Andrew Schutzbank
Medical Director
The Nest, Cambridge, MA Adam Ain
Manager, Practice Operations
Jennifer Kaye Argenti
Director of Learning & Development
Benjamin Berk
Vice President, Business Development & Analytics
Alexis Bradshaw
Manager, Practice Operations
Myke Cameron
Software Developer
Scott Cunningham
Vice President, Finance
Paul Dufault
Manager, Practice Operations
Gianna Marzilli Ericson
Product Manager
Rushika Fernandopulle
Chief Executive Officer
Brian Fitch
Software Engineer
Paul Flaherty
IT & Systems Administration
Dave Jachimiak
Software Engineer
Jess Kadar
Principal Product Manager
Ali Khan
Physician & Clinical Innovator
Whitney Kramer
Manager, Business Intelligence
Eliot Kristan
Devops & Systems Manager
Nicola Majchrzak
Director, Practice Operations
James McElhiney
Chief Technology Officer
Chris McKown
Executive Chairman
Will Mernagh
Senior Developer
Shannon Mills
Manager, Practice Operations
Jennifer Natenshon
Recruiting Manager
John Norman
Chief Software Architect
Zander Packard
Chief Operating Officer
Gerardo Pis-Lopez
Senior Software Engineer
Duncan Reece
Senior Director, Practice Operations
Hannah Richardson
Business Development & Operations Analyst
Patrick Robertson
Software Developer
Tom Russell
Senior Director of Business Intelligence
Steve Schrodel
Vice President, Practice Operations
Matt Sisto
Web Application Designer
Danielle Suttie
Assistant, Finance & Administration
Turntable Health, Las Vegas, NV Elizabeth Ceballos
Operations Assistant
Andrew Christie
Health Coach
Rebecca Frye
Physician
Neil Gokal
Physician
Tessa Koschel
Health Coach
Tammy McCann
Nurse Innovator
Sonya Shearin
Health Coach
Vida Sana Medical Care, Queens, NY Diana Ramirez-Baron
Physician
The American Twine Building 222 Third Street, Suite 3100 Cambridge, MA 02142 617.454.4672 (IORA) info@iorahealth.com www.iorahealth.com
Book Design: Kurt Danielson
November 2013 • Ashland, MA