Funded Projects in Cohort V (Will begin Jan 2024):

What can Dartmouth Health do to Address the Youth Mental Health Crisis?
More than 1 in 4 teens in a primary care waiting room are struggling with their mental health, with insufficient availability of mental healthcare providers/professional treatment options to meet the profound demand. This project aims to identify new approaches to support teen mental health and wellness locally.

  • Project Leads: Julie Balaban, MD and Kay Jankowski, PhD
  • Multidisciplinary Team: Psychiatry, Pediatrics, School Social Worker, The Dartmouth Institute for Health Policy and Clinical Practice, Individual with Lived Experience

CardioPal – Comprehensive Palliative Care for Patients with Advanced Heart Failure
Heart failure is a source of substantial suffering, decreased quality of life, and caregiver burden, as well as one of the most common causes of hospitalization in older adults. This project aims to improve symptom control, goal concordant care, and quality of life for patients living with advanced heart failure, by improving access to palliative care. In so doing, the team expects to reduce utilization of acute care settings, such as the hospital and emergency room, increase options for receiving medical care at home and in the community, and reduce patient and caregiver distress. 

  • Project Lead: Katharine Manning, MD, MBE
  • Multidisciplinary Team: Cardiology, Palliative Care, The Dartmouth Institute for Health Policy and Clinical Practice, Care Management, New England Life Care, Caregiver of Individual with Lived Experience

Increasing Enrollment in WIC for Pregnant and Pediatric Patients Experiencing Food Insecurity
Certain communities in NH experience higher rates of food insecurity and worse health outcomes compared to others. Unfortunately, the majority of individuals eligible for WIC—an evidence-based, publicly funded nutrition program—do not enroll and therefore do not receive benefits that have been shown to improve health outcomes for birthing people and their children. This project aims to develop community-healthcare partnerships to optimize referral streams and outreach strategies, and ultimately, to improve health outcomes for low-income children and pregnant people by increasing enrollment and participation in WIC.

  • Project Leads: Chelsey Canavan, MSPH and Holly Gaspar, MEd, MPH
  • Multidisciplinary Team: Population Health, Center for Advancing Rural Health Equity, Obstetrics & Gynecology, Pediatrics, The Dartmouth Institute for Health Policy and Clinical Practice, Community Action Program Belknap-Merrimack Counties, and Individuals with Lived Experience
Funded Projects in Cohort IV (Jan – Dec 2023):

THRIVE: Teaching Health-Resilience in IBD through Virtual Engagement
Inflammatory bowel disease (IBD), consisting of Crohn’s disease and ulcerative colitis, is a medical condition characterized by chronic inflammation of the gastrointestinal tract. Suboptimal IBD care in adolescents and young adults (AYAs) can have life-altering impacts, increasing risk for hospitalization, surgery, opioid use disorder, and colorectal cancer. This project created a multidisciplinary, virtual clinic that engages AYAs in local gastroenterological care and promotes independent health management.

TREAT-FH (Familial Hypercholesterolemia)
Familial hypercholesterolemia (FH) is a genetic condition that causes high cholesterol. Left untreated, it leads to premature heart attacks, strokes, and death. FH is more common in Northern New England due to a well-documented  “founder effect” resulting from the high frequency of FH in French Canadians who emigrated during the industrial revolution. This project represents a joint collaboration between Dartmouth and the Family Heart Foundation and identified undiagnosed individuals with “probable” FH and engaged them in evaluation and treatment.

  • Project Leads: Kerrilynn Hennessey, MD and Mary McGowan, MD
  • Multidisciplinary Team: Cardiology, The Family Heart Foundation, Pediatrics, The Dartmouth Institute, Thayer School of Engineering, Epidemiology, Patient Representative

    Learn more about this project through the new website.

Returning Home: Improving Post-Incarceration Care Transitions
Ninety-five percent of incarcerated persons will reenter the community, yet most health systems are underprepared to support post-incarceration care transitions. During reentry, care is disrupted and delayed due to a variety of factors. This project developed a multidisciplinary re-entry planning team, utilizes peer support, and created facilitated, timely access to Primary Care at DH Concord.

  • Project Lead: Milan Satcher, MD, MPH
  • Multidisciplinary Team: Primary Care, Connected Care, The Dartmouth Institute, New Hampshire Department of Corrections, Patient Representatives

Mitigating Moral Injury via Healing Social Networks
Moral injury is defined as the psychological, behavioral, social, and spiritual sequelae of exposure to a moral transgression committed by oneself or others. Data across 28 months of the pandemic indicate that >75% of health care workers are experiencing routine exposure to moral dilemmas and morally injurious events, influencing emergent mental health disorders, eroded social connection, degraded healthcare quality, and increased intentions to leave the nursing workforce. This project developed interventions to re-establish healthy and supportive social networks that empower positive social meaning, service, and connection.

  • Project Leads: Andrew Smith, PhD and Karen Fortuna, PhD
  • Multidisciplinary Team: Psychiatry, Family Medicine, Critical Care, Nursing, The Dartmouth Institute, Department of Veterans Affairs, Patient Representatives
Funded Projects in Cohort III (Jan – Dec 2022):

The PACS Partnership: Bringing the DH Promise to Post-Acute COVID Syndrome Care
For as many as half of people impacted by COVID-19, symptoms persist after having the virus. These symptoms can profoundly impact health and quality of life. This project developed peer-to-peer support and established a registry-enabled learning health system.

Establishing and Evaluating a Program to Improve Access to Behavioral Healthcare in Gastroenterology
Gastrointestinal problems can reduce quality of life and behavioral health interventions have been proven to reduce symptom burden. This project developed innovative workflows, content, delivery mechanisms that extended the reach of behavioral health services in GI.

Facilitating Lung Cancer Screening in a Rural Population
Lung cancer screening is currently recommended for at-risk groups, yet is highly underutilized, especially among rural populations. This project evaluated and utilized novel strategies to increase lung-cancer screening in the DH catchment area.

Funded Projects in Cohort II (Jan – Dec 2021):

I*CARE: Improving Care – Accelerating Recovery & Education
Pediatric mental health patients awaiting transfer to inpatient treatment facilities are monitored for safety, but typically do not receive treatment during this time of boarding. This project redesigned care for pediatric patients experiencing acute mental distress by initiating treatment during the boarding period, providing a head start on recovery.

Dartmouth CARES: Community Aging Resources for Elderly Surgical Patients
Older adults undergoing surgical procedures are at higher risk for complications after surgery than younger adults. This project enhanced the surgical care experience for older adults by improving surgical education, ensuring goals of care discussions, promoting early identification of vulnerability for frailty and delirium, and strengthening support at home. As part of their Incubator work, this team is submitting for Geriatric Surgery Verification for DHMC by the American College of Surgeons.

To the Point: Connect to Cure – Care Innovation for Viral Hepatitis, STIs, and HIV
Stigma, cost, and access issues cause individuals with viral hepatitis, sexually transmitted infections, and HIV to be poorly connected to traditional healthcare systems. This project utilizes novel peer support strategies and telemedicine to redesign access to testing and care for people at risk for these conditions.

GITT RREAL: Goal-oriented, Innovative Technology and Team-based care to Reduce Readmissions, ED visits, and Length of stay
Patients with multiple comorbidities and hospital stays of 5+ days have high rates of readmission to the hospital. This project designed an inter-professional transitional care management model that increases the likelihood that patients see their own DH primary care provider less than 7 days from discharge, which literature has shown reduces rates of re-admission.

Funded Projects in Cohort I (Mar/May 2020 – Feb/Apr 2021):

Hope Grows at Home: Establishing Home-Based Oral Feeding to Bring Pre-Term Infants Home from the ICN Sooner
Many preterm babies stay in intensive care nurseries (ICN) after medical care only to gain weight and be fed via nasogastric tube. Data suggest that extended ICN stays can harm infant development and create financial burden. This project redesigned care for stable preterm infants by transitioning their feeding from the hospital to the home with extensive medical support and monitoring.

Outpatient IV Antibiotic and Addiction Therapy for People Who Inject Drugs
People who inject drugs are often excluded from outpatient parenteral antibiotic therapy (OPAT). Data suggest the use of peripherally inserted central catheters and OPAT is safe in these patients when they also receive treatment for substance use disorder (SUD). This project designed a new care model that developed individualized treatment plans integrating infectious disease, SUD, and OPAT treatment.

AVOID – Accessible Individual Outpatient Diuresis
Patients with advanced heart failure are frequently admitted for IV diuresis. This project created DHMC’s first IV diuresis clinic and outpatient management program, which includes transitioning diuresis to local community health centers and the home with the support of visiting nurses.