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Working to Rebuild the Community Nursing Model in the Upper Valley

  • Cindy Grigel is the newly established Community Nurse of Thetford working free of charge with Thetford Residents that need resources, medication education, counseling and advocacy in navigating the health care system. Grigel comes to the 10 hour per week position after 30 years working as a nurse in critical care and other departments at Dartmouth Hitchcock, and still maintains a position with Health South Rehabilitation Hospital evaluating patients at Dartmouth Hitchcock and New London Hospitals after serious illness or injury and before they are released into rehab. Grigel was photographed at Dartmouth Hitchcock Medical Center in Lebanon, N.H. (Valley News - James M. Patterson) Copyright Valley News. May not be reprinted or used online without permission. Send requests to permission@vnews.com.

  • Ellen Thompson, one of two parish nurses with the Lyme Congregational Church, sits outside the church in the center of Lyme, N.H., on April 22, 2016. (Valley News- Sarah Priestap) Copyright Valley News. May not be reprinted or used online without permission. Send requests to permission@vnews.com.



Valley News Staff Writer
Sunday, April 24, 2016

Lyme — When Ellen Thompson decided, in 2011, to retire after nearly four decades of work in various nursing and management positions at Mary Hitchcock Memorial Hospital, she began “looking for something to kind of fill my time.”

Thompson found it in the town where she lives, as one of two part-time parish nurses employed by the Lyme Congregational Church. The job entails “deciphering what happens in the health care industry for people,” Thompson said. The ciphers can be medical or financial.

The nurses bring to bedsides and their communities “assessment ability and knowledge about options for appropriate interventions,” according to the Upper Valley Community Nursing Project.

Thompson and the other experienced nurses now working as community or parish nurses are helping to create a caregiving space that complements the role of large-scale providers whose operations must follow the funds and rules of government insurance programs, backers say.

“A lot of the role is as an advocate acting to help people navigate in the complicated health care system and to help fill in the gaps in our health care system,” said Cindy Grigel, the newly hired community nurse in Thetford.

Gaps are not a new discovery. A 2011 assessment of local health needs by the Mascoma Valley Health Initiative identified as the No. 1 priority coordination of care services among “a patchwork of private nonprofit organizations, state-funded programs, and municipal offices.”

That patchwork is familiar territory to many of the Upper Valley’s parish and community nurses. Most have worked full-time at Dartmouth-Hitchcock or other area hospitals and clinics. In their new role, they work just off the grid of institutional and financial arrangements that define health care in this region.

That independence is a good thing, according to backers. “Because they are not fully attached to a facility (they are) able to be very flexible and nimble,” said Laurie Harding, co-director of the local Community Nursing Project.

Said Thompson: “You get to do the things that you can’t necessarily do when you’re totally in the system.”

“When you have somebody who doesn’t understand their new diagnosis, you don’t have to spend just 20 minutes with them, you can spend an hour,” Thompson said.

“You don’t have to just deal with them, you can actually know their family.”

Thompson recalls visiting a man from Lyme in the hospital. When he was discharged, she drove him home. They found the power off. So Thompson lined up a neighbor to look in on the man, who had lost 50 pounds and needed help. She made him a peanut butter and jelly sandwich, filled his medication box, bought him bottled water and made sure he would have heat during the night.

“I was planning on being with him for about an hour,” and ended up spending six, Thompson recalled. “The thing about this job is that you do have that flexibility.”

Such efforts have been noticed within the local health care mainstream.

“I can understand the joys of being able to address the wide variety of social determinants” that affect patients’ health, said Sally Kraft, vice president for community health at D-H.

“We have been working with community nurses and trying our very best to understand ... what is the best way to provide high-value support to patients in the community,” Kraft said

Yet it is an open question whether a model for community nursing will emerge that is sustainable and preserves the flexibility that the nurses say is so important.

Six years after the passage of the Affordable Care Act, health care reform remains a focus of policy debates and analyses throughout the country. Influential voices in those discussions emanate from such Upper Valley institutions as D-H and the Dartmouth Institute for Health Policy and Clinical Practice, where work focuses on such knotty issues as population health and payment reform.

The community nursing movement grew in the shadow of those debates. The movement began with a recognition that “care at home for frail elders was very much driven by … Medicare and Medicaid,” said Harding, who worked as a nurse and was a Democratic state representative from Lebanon for 10 years.

Dennis McCullough, a physician who is the project’s other co-director, said patients faced a system focused on what he called “technical nursing,” where work generally entailed caring for the sick and responding to crises: “Almost everything was routed through the hospitals.”

To better respond to community needs, the project turned to what its website describes as “a holistic philosophy of nursing that dates back to the mid 19th century.”

For a time, there were town and district nurses in the Upper Valley “whose mission was education, advocacy and problem solving,” Valley News contributor Steve Taylor wrote in 2014. By the 1970s, those positions had been absorbed into regional visiting nurse organizations.

But the transition away from the previous town nurse structure came with what Harding terms some “community sadness.”

So more than three years ago, according to Harding, she and McCullough started exploring ways to revive community nursing. Said McCullough: “We decided to build on what (existed) in the Upper Valley.”

What existed were “aging in community” organizations in a number of towns. Also, churches in Lyme and Hanover had begun employing and supporting parish nurses.

Harding said advocates looking to make health care more responsive to the needs of seniors began to ask, “Why couldn’t we take that model and apply it to communities?”

Harding and McCullough found that weaving together an effort spanning multiple Upper Valley towns would take time. Said Harding: “Dennis and I realized very quickly we couldn’t be impatient about this.”

Harding and McCullough set out to connect those organizations with resources, help them add professional nurses to their mix of volunteer services and, as Harding put it, do some “cheerleading.”

In ways, it seemed an inopportune time to turn to nurses to fill in the gaps in health care.

A well-documented shortage of nurses has crimped operations and budgets at a range of health care facilities throughout New Hampshire and Vermont.

But although the town nurses must be licensed, they seem to exist outside of the region’s seller’s market for nursing services.

Partly that’s because the posts don’t offer full-time work or benefits, or pay that’s competitive with the wages at larger, institutional providers.

“It’s not about the money,” Harding said.

Currently, there are community or parish nurses in seven Upper Valley towns, including the two parish nurses in Lyme; community nurses in Hartland and Thetford; a nurse serving the Eastman community in Grantham; and nurses affiliated with the First Baptist Church of New London and the Church of Christ at Dartmouth in Hanover. A nurse in Lebanon works as part of team supported by the Community Nursing Project, D-H and the Grafton County Senior Citizen Council. The Sharon Health Initiative is in the process of hiring a nurse in that town.

Community nurses don’t provide direct care. The work of dressing wounds or administering intravenous fluids is filled by visiting nurses or hospice providers who are often reimbursed by Medicare, Medicaid or private insurers.

Instead, said Grigel, the Thetford nurse, her new role is “kind of what nursing is all about — looking at the whole person and the whole support system.”

Thompson, a Lyme nurse, said that, during her 15-hour work week, she might join with a local walking group, help guide a balance class, be available for office hours, make a few house calls and, along the way, take a few blood pressure and glucometer readings. The job also entails public education such as might occur in a gathering to discuss preparing advance health care directives, she said.

Sometimes it feels like “a pretty isolated job,” Thompson said. She provides “nursing expertise and not hands-on care,” but may find herself called upon to offer opinions, education, resources and referrals.

Patients and families don’t pay for the services provided by the local community and parish nurses. Funding mostly comes from town appropriations, grants and support from local churches and organizations.

In Lyme, where Thompson and a colleague report to the pastor of the Congregational Church, support comes from that church, the town, the Byrne Foundation and local women’s and men’s service organizations.

That support comes with a minimum of bureaucratic strings, but may vary from year to year and is geared to support a pay structure that doesn’t match salaries inside the system.

Other, more reliable funding sources have yet to materialize. Kraft, of D-H, said payment models are still taking shape and community nursing has yet to establish itself as a regular recipient.

Criteria to assess community nursing include whether it improves patients experiences and the quality of care and if it shows to be the best use of available resources.

“We’re still learning,” she said. “We’re doing our very best to gather data.”

At a recent open house to introduce Grigel to the town of Thetford, state Rep. James Masland said some state funding for the positions might eventually be possible. However, it might not be completely welcome if it came with more rules or requirements, he said: “I don’t think any top-down stuff would be particularly helpful.”

Other backers talked guardedly of the possibility of, at some undefined future point, incorporating funding for the position in the town budget.

In any case, community and parish nursing programs that plan to stick around still have work to do to firm up their financial and organizational foundations.

“Our next concern (is) how to help the communities to make it sustainable,” said Harding. “There’s no good answer. We don’t fit the model.”

Rick Jurgens can be reached at rjurgens@vnews.com or 603-727-3229.
 

Correction

The Sharon Health Initiative is in the process of recruiting and hiring a community nurse for the town of Sharon, but the job is not yet filled. An earlier version of this story misstated the status of the program.