2017 Annual Report Penobscot Community Health Care

A Message from the President & CEO

Lori Dwyer, Esq. — President and CEO

It is my great privilege to share some thoughts with you during my first year as President and CEO of this amazing organization. I marvel every day as I watch and learn from the everyday miracles at work in our practices – in our attention to the complete person as we deliver integrated primary care; as we feed and shelter our neighbors in our homeless shelter; as we provide support, skills and job training at the Clubhouse to those with severe mental illness; during integrated care visits in nursing homes; when we provide the miracle of hearing and speech to children and seniors in our speech/audiology practice; and as we care for each other in the course of this infinitely rewarding work.

In this report, we focus on the PCHC integrated primary care model. The word “integrated” comes from the Latin “integrates,” meaning “I make whole, I renew, I repair, I begin again.” This is fitting, because it describes what we strive to do: make people whole, support renewal, repair old wounds. We attend, as Dr. Gardner says, to bio-psycho-social needs – biology, brain health, and the need for social stability and connection.

To do this, we work in teams, where each team member brings a different expertise and perspective, and makes the group smarter. The work is always, and primarily, integrated — philosophically, and in the make-up of the care teams and the leadership team. This is part of our PCHC “DNA.” We know that no one has all the answers, that together we are better. We know that an integrated approach demands humility, because only in giving and accepting help can we deliver the best care.

I am fortunate to stand beside PCHC’s 750 employees to advance our shared mission of access, integration, quality, and kindness for all, and in our vision for a future where health encompasses physical and emotional wellness, personal dignity, and a sense of belonging.

A Message from the Vice President of Medical Affairs

Noah Nesin, MD — Vice President of Medial Affairs

Not long ago, Lori asked those of us on the Executive Leadership team to use a single word to describe PCHC. You might imagine that, depending upon one’s mood and the exigencies of the moment, the responses could be colorful, but the word that came to my mind was “striving.” I chose this after consideration of all of the work we do together to fulfill our mission, to live up to our values, and to be among the leaders of our region and state in innovative responses to the healthcare challenges of our time. The breadth of our initiatives is admittedly audacious, and disruption is the confederate of audacity, but our boldness also serves our shared passion. It stimulates our collective creativity and compels us to work together to achieve a higher standard for ourselves and for the people we serve.

From quality initiatives to our embrace of the value based purchasing environment, from Joy in Medicine to Inter-professional Education, from substance abuse screening to medication assisted recovery, and from our constant effort to improve our patients’ experience to our advocacy in the public policy arena, we are able to undertake these efforts because we are, together, a team. Providers, administrators, clinical staff, and people in support services respect and value each other and understand that each of us is critical to our shared success. This is our highest model of integration. It is not perfect, but, in working to improve it, we learn together, and we serve our patients, community and each other more fully. We strive.

Our Mission

We provide comprehensive, integrated primary health care services for all to improve the health and wellbeing of our patients and the Maine communities we serve.

Our vision for success is a community in which everyone has access to quality, cost effective health care, where people are empowered to advocate for their personal goals and needs and are supported by community based resources, and where health encompasses physical and emotional wellness, personal dignity and a sense of belonging.

We value patient centered care, respect, passion, quality, innovation, and collaboration.

Our strategic plan goals:

  1. Improve the quality of patient experience and clinical care.
  2. Increase employee engagement by building a culture that fosters excellence and quality through continuous learning, meaningful collaboration and a commitment to employee well being.
  3. Strengthen PCHC’s sustainability.
  4. Strengthen PCHC’s infrastructure.
  5. Enhance mission impact through community and state leadership.
  6. Ensure board sustainability.

Financial Report

PCHC continues to focus on long-term sustainability through improvements in revenue cycle management, revenue diversification, infrastructure, and recruitment and retention.

Net Revenue

2017 Statistics

Caring for the Whole Person

In 2017, Unlimited Solutions Clubhouse in Bangor assisted 46 Members in attaining competitively paying jobs. Since opening in 2012, U.S. Clubhouse has helped a total of 214 Members obtain employment.

In 2017, the Hope House Health & Living Center served an estimated 52,000 meals to those who are homeless or peri-homeless in our community. The Hope House emergency shelter served 624 unique individuals, totaling 22,725 bed nights throughout the year.

2017 Statistics

2017 Highlights


Combating an Epidemic – PCHC continued to be on the front lines of the opioid epidemic. Our clinical staff embraced best practices, and continue to push toward better and better treatment of individuals suffering from Substance Use Disorder (SUD). Dr. Noah Nesin, Dr. Trip Gardner, the teams in Belfast, Brewer, and Old Town, the pharmacists and care managers along with many other PCHC staff have worked tirelessly to educate our community about SUD and to increase access to treatment and services, most recently at the Brewer Medical Center’s new rapid access SUD clinic. Though the hard work continues, the forces against us can feel overwhelming. PCHC has continued to innovate in this area, including through our Controlled Substances Stewardship Committee (formerly “CSI”), and the CHAMP clinic, as early adopters of strong internal controls around the prescribing of controlled substances, by leading the effort through the Community Health Leadership Board in the development of community-wide prescribing standards, and much more.


Dr. Robert P. Allen Quality Awards – This award is bestowed annually in honor of exceptional innovation, commitment to quality improvement, and excellence in patient care. In 2017, the award was given for exceptional work surrounding SUD, and presented to David Loxterkamp, MD, Tim Hughes, MD, Mary Beth Leone, LCSW, and Carol Kuhn, MD (Seaport CHC); Stephanie Partridge, PMH-NP, Becky McMahan, LCPC, LADC, and Stephanie Riehl, PMH-NP (Penobscot CHC); David Rawcliffe, DO, George Case, FNP, Jennifer Moss, LCSW, and Nathan McKnight, LCSW (Brewer Medical Center); Hope House Health and Living Center; the Controlled Substance Initiative (CSI) Committee; Heather Blackwell, Operations Project Manager (Administration); and Patty Hamilton, FNP, Bangor Public Health Director. The awards were presented at PCHC’s 2017 Annual Meeting in April, during which Kathryn Power, M.Ed. Regional Administrator, Region One of the Substance Abuse and Mental Health Services Administration (SAMHSA), was the Keynote Speaker.


Schmidt Institute for Innovation – In honor of our incredible founding CEO, Ken Schmidt, who retired in 2017, and in partnership with St. Joseph Healthcare, PCHC created Ken’s namesake – the Schmidt Institute for Healthcare Innovation. Under the Institute, we will enhance our ability to evaluate and publish research on the innovative work we do, with the goal of speeding up and spreading breakthrough innovations. The first meeting of the Schmidt Institute Advisory Committee was February 1, 2018.


Patient Safety Organization – PCHC, in collaboration with Maine Primary Care Association, became a founding member of a new Patient Safety Organization (PSO). The goal of a PSO is to create a formal, internal review system for patient safety incidents in primary care to reduce medical errors to zero and engage in clinical process improvement to better safety and quality. This is a groundbreaking initiative, and we are proud to partner with the MPCA in pioneering this work.

Joy in Medicine (“JIM”) Workgroup – After 9 meetings of physicians, NPs, PAs, concerned staff and leaders from across the organization, the JIM Workgroup generated a list of recommendations to pilot in 2018 around reducing burnout and improving joy in medicine. This list includes 30-minutes appointments for primary care visits (eliminating 15 minute appointments), a pilot program to evaluate the effectiveness of the use of scribes during primary care visits, an organizational goal of developing a toolkit for clinical staff to reduce burnout, a workgroup looking for ways to reduce desktop burdens, enhanced training for care teams, and more. The JIM workgroup will continue to meet quarterly in 2018 to review ongoing initiatives and discuss further innovations.

Awards and Recognitions

Noah Nesin, MD, FAAP, was recognized by Maine Quality Counts with the first Lisa LeTourneau Award for Excellence in Primary Care.

Awards and Recognitions

Maggie Vance, CPhT, Prescription Refill Specialist at Penobscot Community Health Center, and Abagail Smith, Housing Navigator at Hope House Health & Living Center, were named PCHC’s 2017 Clinical and Non-Clinical Employees of the Year.

Awards and Recognitions

Amy Langley, FNP, received the Maine Primary Care Association (MPCA) Nurse Practitioner Excellence Award.

PCHC was recognized for the seventh year in a row as a “Leader in LGBT Healthcare Equality” by the Human Rights Campaign (HRC) Foundation.

Adrienne Carmack, MD, received a Special Achievement Award from the American Association of Pediatrics.

Space and Access Improvements

Helen Hunt Health Center Walk-In Care was fully renovated and doubled in size.

Space and Access Improvements

Brewer Medical Center renovated and expanded to create Pod 4, a space to provide rapid access substance use disorder treatment.

Space and Access Improvements

The Downeast School Dental Clinic was finalized in 2017 and by the end of the year our team saw 60 children needing dental care. Kudos to the PCHC dental team for their incredible work on this start-up. This space provides desperately needed dental care to the Downeast community children, and is the first school-based health center for PCHC within a Bangor school.

Winterport Community Health Center renovations were nearly completed. The official opening will be in late spring 2018.

The PCHC Information Services office was renovated to fully accommodate and consolidate the IT and Data teams in one functional space at 992 Union Street, Bangor.

PCHC acquired the total Jackman health facility through a donation by Maine General Health in September.

Chiropractic Care was added to PCHC’s roster of services. Three chiropractors were hired to provide care at PCHCenter, Brewer Medical Center, and Helen Hunt Health Center.

Dental Care at Helen Hunt Health Center expanded with a full-time dentist in August.

Penobscot Community Health Center Pharmacy in Bangor began Saturday hours.


Hope House Health and Living Center received a four-year $2 million dollar grant from the Substance Abuse and Mental Health Services Administration (SAMHSA). The Wellness Integrated Supportive Housing or WISH grant will provide PCHC’s Hope House the resources necessary to guide homeless or at risk persons to permanent housing with supports in place to ensure the most vulnerable persons suffering from mental health and substance use disorders have greater recovery chances, treatment prospects, and longterm stability.


PCHC’s Outreach and Enrollment Specialists again made an incredible impact on our patients' and communities' ability to access health care during the Marketplace Health Insurance Enrollment Period. PCHC’s O&E team completed 520 enrollments, fielded 1140 calls, had 466 in-person appointments, and assisted 1754 people overall.


Community Care Partnership of Maine (CCPM) ACO achieved shared savings in its first year of participation in the Medicare Shared Savings Program (MSSP). For the 2016 performance year, CCPM achieved $4.3 million in total savings for Medicare, with $2.1 million in shared savings distributed in CCPM and its member organizations.

Unlimited Solutions Clubhouse celebrated their 5-year anniversary in 2017 and again achieved accreditation through Clubhouse International.

PCHC and the State of Maine weathered a drastic Halloween windstorm causing widespread power outages and the closure of practices and services. Staff united and redeployed to practices with electricity to provide necessary care for patients.

PCHC’s Postgraduate Year One (PGY1) Community Pharmacy Residency Program was re-accredited by the American Society of Health-System Pharmacists.


Ken Schmidt, MPA retired as President & CEO from PCHC at the end of August 2017 after 15 years of dedicated service.

Lori L. Dwyer, Esq., PCHC’s Senior Vice President, General Counsel, Compliance Officer and Risk Manager, was announced by the Board of Directors as PCHC’s President and CEO effective September 1.


MaineGeneral closed the Jackman Nursing home in September and PCHC has worked to find sustainable funding for maintaining urgent care in Jackman.


At the time of the CEO transition, Megan Sanders, Esq., became PCHC’s General Counsel and continues to function as Vice President of Human Resources.

PCHC’s wonderful volunteer Board of Directors welcomed new members Kelley Strout, RN, PhD, Assistant Professor, UMaine; Meredith Jones, former President and CEO of the Maine Community Foundation; and Jessamine Pottle, Marketing Director, CES, Inc.

A Message from our Chief Psychiatric Officer

Integrated Care

Trip Gardner, MD — Chief Psychiatric Officer

People are integrated and so are we!

I have never heard a patient say: “I sure wish that I could go to a different person in a different place to receive help for each of my different biological, psychological and social challenges, and I would hope they would never communicate or work on my problems together the way I live with them.”

Instead, what I have heard our patients say is: “For me, the best part of this is that we rarely need just psych or just medical services. Often, as in my case, we have interconnected medical issues. ‘General’ health issues that affect psychiatric health or vice versa. In the past, I was forced to be the point person between my providers who had absolutely nothing to do with each other. That was very difficult. This process has become a breeze now and takes the burden off of me, which lets me concentrate on getting better.”

“People are integrated” sounds very simple when you look at things from a patient’s perspective, but it is much more complicated when you look at it from the eyes of a healthcare system. Penobscot Community Health Care (PCHC) made a decision, upon its inception, to look at healthcare through the patient’s eyes - to look with the patient at their problems, their solutions, their bodies, their minds, their spirit, and their environment as if they are all connected; to recognize that people don’t separate their multidimensional selves like a puzzle and people don’t judge how well they feel by how perfect each puzzle piece is. Every day, people effortlessly put the pieces that make up their lives together and, if we intend to be patient centered, we must follow their lead.

“This process has become a breeze now, and takes the burden off of me, which lets me concentrate on getting better.”

— PCHC Patient

We asked ourselves: “How can we serve people in their interest if we are not integrated in our care?” We questioned “why would we expect people to break themselves apart, to work on each piece of themselves without the healthcare clinician caring about how the piece they are working on fits with all of the other pieces that make us whole, that make us human.”

In 2001, our founding physician, Dr. Barbara Vereault, DO, came together with our founding mental health clinician, Rebecca McMahan, LCPC/LADC, to start our psychiatric integrated primary care program. This model today has grown to 40 multidisciplinary mental health clinicians working side by side in the same systems, with 100 primary care clinicians offering multiple psychiatric services that are integrated into the individual’s primary care within their patient-centered medical home all in the same integrated health record. These services include “curbside” informal case discussions, healthy behavior assessments and interventions, psychiatric (including substance use disorder) evaluations and management, group and individual psychotherapy, and psychiatric medication management.

PCHC’s model of integrated care is unique, in that it attends to the psychiatric needs of our community across the spectrum of care—from increasing healthy behavior by removing psychological and social barriers to improve outcomes in the management of chronic medical diseases; to preventive screening for factors that elevate risk, including trauma, risky substance use and environmental obstacles like loss of income, lack of health insurance, insecure housing and inadequate food supply; to identifying the 50% of mental health problems in our society that go unidentified; to treating effectively mild to moderate psychiatric conditions in primary care that are a roadblock to wellness; to improving the biopsychosocial health of those with serious brain illnesses, like schizophrenia, for whom the average age of death usually secondary to preventable cardiovascular causes in our mostly segregated healthcare system is in the early 50s and inexcusably getting worse. Our holistic, wrap-around model focuses on the patient not the disease and has two primary goals:

  1. Destigmatization - psychiatric medical conditions are treated in the same environment and in the same way as other medical conditions. This model moves care away from the separatism that has existed between “mental health” and all other medical health that has served to isolate and fragment care both in individual cases and in the eyes of society.
  2. Defragmentation - psychiatric care is provided within the patient’s primary care and documentation is unified in an electronic medical record.
“It is great having my providers in the same building because they talk with each other at the time of the problem rather than me having to wait. By having both services together and connected, it is far easier on me to get coordinated services which helps to get to the root of the problems more quickly. I can’t imagine where I’d be now if it weren’t for the great team that pulled together to make sure I didn’t fall through the cracks. Today I have control over my health; it does not have control of me. The coordinated care allows me to feel like I can go out and be a part of the community.”

— PCHC Patient

Additionally, we see the benefits of our integrated model to be: multidisciplinary cross-education; extending our community’s limited supply of psychiatric care clinicians; enhancing the ability of the health center to practice care that is trauma informed; improving general medical outcomes; decreasing healthcare cost by being especially mindful of the fact that our state’s highest utilizers of healthcare services are typically challenged by difficult living situations and multiple chronic medical conditions, including the psychiatric diseases of the brain; lowering occupational days lost by treating psychiatric conditions, recognizing, for example, that mood disorders are second in the country’s most disabling health conditions, and increasing our flexibility to acutely meet the needs of our community.

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