Eastern Maine Healthcare Systems

Recent rise in rates of opiate replacement therapy among pregnant women have resulted in increasing number of infants requiring treatment for neonatal abstinence syndrome (NAS). Short-term and long-term developmental outcomes associated with prenatal opiate exposure are discussed, including symptoms and severity of NAS, and early cognitive and motor delays. Maternal and infant risk factors are discussed, and include patterns of maternal substance use during pregnancy, genetic risk, polysubstance exposure pharmacological treatment for NAS and breastfeeding. The importance of characterizing corollary environmental risk factors is also considered.

INTRODUCTION: This study assessed whether patient portals influence patients' ability for self-management, improve their perception of health state, improve their experience with primary care practices, and reduce healthcare utilization. METHODS: ), experience with the provider/practice (CG-CAHPS), and healthcare utilization (admissions and ED visits). RESULTS: A total of 94 patients were enrolled, and 92 (Intent to Treat) were followed up for 7 months to assess their experience, and for 12 months to assess healthcare utilization. Seventy four (mean age 60+13 years) used the portal (Users). Comparison between baseline and 7-month follow-up showed no statistically significant improvements in self-efficacy, perception of health state or experience with the primary care practice. Only functional status improved significantly. ED visits/1000 patients were reduced by 26% and 21% in the Intent to Treat and Users groups, respectively. Hospital admissions/1000 patients were reduced by 46% in the Intent to Treat group and by 38% in the Users group. DISCUSSION: For patients in care coordination, having access to patient portals may improve access to providers and health data that lead to improvements in patients' functional status and reduce high-cost healthcare utilization, but it does not seem to improve self-efficacy, perception of health state, or experience with primary care practices. CONCLUSION: In this study, the use of patient portals improved functional status and reduced high-cost healthcare utilization in patients with chronic conditions.

Objectives The clinical outcomes of patients treated with spatially fractionated GRID radiotherapy (SFGRT) for bulky tumors of the head and neck at a single institution were evaluated retrospectively. Endpoints of interest included tumor response, symptom improvement, treatment tolerance, and adverse events. Methods Institutional review board approval was obtained prior to study initiation. The institutional database was queried for patients with tumors of the head and neck treated with SFGRT between August 2007 and April 2015. Medical records of identified patients were reviewed for treatment details and clinical endpoints of interest. SFGRT was delivered in one fraction of 15 gray (Gy) or 20 Gy; 6 megavolt (MV) or 18 MV photon beams were passed through a multileaf collimator (MLC)-based or brass GRID template. All patients had a planned course of conventionally-fractionated external beam radiotherapy (EBRT) to begin on the day following SFGRT delivery. Results Twenty-one consecutive patients meeting study criteria were identified. The most common tumor histology was squamous cell carcinoma. Median patient age was 59 years (range 13 - 83 years); median maximum tumor dimension was 9.5 centimeters (cm) (range 5.0 - 25.0 cm). Fifteen patients (71.4%) completed their full course of EBRT. Twelve patients were treated with palliative intent for local tumor symptoms, of which 54.5% experienced some degree of symptom improvement. Of nine patients treated with curative intent, 44.4% achieved a clinical complete response (CR). Concurrent chemotherapy was administered in 12 patients, with all patients being treated having definitively received chemotherapy. Radiation Therapy Oncology Group (RTOG) grade three or higher skin toxicity occurred in five patients; no grade five events were reported. Conclusions Our institutional experience suggests that SFGRT is a feasible treatment option for the palliative or definitive management of large tumors of the head and neck. In combination with EBRT, SFGRT can provide timely symptom management and improve patient quality of life in the palliative setting. In the definitive setting, the addition of chemotherapy to SFGRT and EBRT can result in an excellent clinical response. Treatment toxicity was found to be within an acceptable range. When considering SFGRT for patients with these challenging presentations, careful patient selection is needed to identify those who will likely tolerate a full course of EBRT following SFGRT, as these patients are most likely to receive maximal benefit from SFGRT treatment. More data on the feasibility and efficacy of this radiation modality will be helpful for continued optimization of SFGRT delivery and patient selection.

PURPOSE: Unprecedented efforts are underway across the United States to electronically capture and exchange health information to improve health care and population health, and reduce costs. This increased collection and sharing of electronic patient data raises several governance issues, including privacy, security, liability, and market competition. Those engaged in such efforts have had to develop data sharing agreements (DSAs) among entities involved in information exchange, many of whom are "nontraditional" health care entities and/or new partners. This paper shares lessons learned based on the experiences of six federally funded communities participating in the Beacon Community Cooperative Agreement Program, and offers guidance for navigating data governance issues and developing DSAs to facilitate community-wide health information exchange. INNOVATION: While all entities involved in electronic data sharing must address governance issues and create DSAs accordingly, until recently little formal guidance existed for doing so - particularly for community-based initiatives. Despite this lack of guidance, together the Beacon Communities' experiences highlight promising strategies for navigating complex governance issues, which may be useful to other entities or communities initiating information exchange efforts to support delivery system transformation. CREDIBILITY: For the past three years, AcademyHealth has provided technical assistance to most of the 17 Beacon Communities, 6 of whom contributed to this collaborative writing effort. Though these communities varied widely in terms of their demographics, resources, and Beacon-driven priorities, common themes emerged as they described their approaches to data governance and DSA development. CONCLUSIONS: The 6 Beacon Communities confirmed that DSAs are necessary to satisfy legal and market-based concerns, and they identified several specific issues, many of which have been noted by others involved in network data sharing initiatives. More importantly, these communities identified several promising approaches to timely and effective DSA development, including: stakeholder engagement; identification and effective communication of value; adoption of a parsimonious approach; attention to market-based concerns; flexibility in adapting and expanding existing agreements and partnerships; and anticipation of required time and investment.

During President Barack Obama's first primetime press conference, reporters asked primarily about the state of the economy and terrorism. Wedged between questions on these two vital issues was a query from the Washington Post's Michael Fletcher: Question: What is your reaction to Alex Rodriguez's admission that he used steroids as a member of the Texas Rangers? Obama: You know, I think it's depressing news.... And if you're a fan of Major League Baseball, I think it - it tarnishes an entire era, to some degree. And it's unfortunate, because I think there are a lot of ballplayers who played it straight. And, you know, the thing I'm probably most concerned about is the message it sends to our kids. What I'm pleased about is Major League Baseball seems to finally be taking this seriously, to recognize how big a problem this is for the sport, and that our kids hopefully are watching and saying, "You know what? There are no shortcuts, that when you try to take shortcuts, you may end up tarnishing your entire career, and that your integrity's not worth it." That's the message I hope is communicated.1 /="/">Situating the use of steroids by baseball players on the same level as the economic meltdown in the U.S. and the war in Afghanistan may seem strange, but less than two weeks later in his weekly Op-Ed column in the Sunday New York Times, Frank Rich produced a similar list of what he saw as the major evils that were denied during the Bush administration: "Steroids, torture, lies from the White House, civil war in Iraq, even recession ....",2 As to steroid denial in particular, Rich noted, "[a]nyone with eyes could have seen that Sammy Sosa and Mark McGwire resembled Macy's parade balloons in their 1998 home-run derby . . . ."3 And in its February 23rd issue, the cover of the New Yorker featured a portrait of Alex Rodriguez signing autographs for young children whose arms were bloated like balloons. As we will explore in this Article, some ethicists think that the concern about drugs used for "enhancement," including steroids used by baseball players to increase their strength, is misplaced, and that adult athletes should be able to use whatever enhancers they want, so long as they are not dangerous to their health.4 Putting aside for a moment the health dangers of steroids on adults-which are contested-the other two primary reasons for banning the use of performance enhancers in baseball are that they are, as President Obama noted, a form of cheating that undermines the integrity of the game, and that they encourage emulation by children. Sports has been the primary arena in which what might be termed the "enhancement debate" has played out, and, at least until the publication of the Mitchell report in late 2007, most of the attention focused on the Olympics and devising ways to detect cheating by athletes who were using drugs.5 In George Mitchell's recounting, as well as a recent survey by the Wall Street Journal, the two teams that had the most players who used steroids were George W. Bush's old team, the Texas Rangers, and the New York Yankees. 6 As Red Sox fans, we can, of course, be accused of prejudice, especially against the Yankees. So it is probably best we leave the sports debate to others. Instead, our focus in this Article is on the use of performance enhancing drugs in the arena that bracketed the Alex Rodriquez question to the president: the war against terrorism, and specifically the unasked question regarding the use of "enhancement" drugs by U.S. soldiers in combat.

Introduction: This project implemented an integrated patient self-reported screening tool in a patient portal and assessed clinical workflow and user experience in primary care practices.Methods: An electronic health risk assessment based on the CMS Annual Wellness Visit (AWV) was developed to integrate self-reported health information into the patient’s electronic health record (EHR). Patients enrolled in care coordination tested the implementation. The evaluation plan included quantitative and qualitative measures of patient adoption, provider adoption, workflow impact, financial impact, and technology impact.Findings: Seventy-two patients completed the sample AWV, and 80% of the questionnaires had clinical findings that required provider follow-up. Patients expressed satisfaction with the portal, as it enabled them to view their health record and enter information. Implementation did not reduce office staff time. Providers and office staff agreed that an electronic system for adding information to their record would increase patient satisfaction, but they expressed concern with the need to promptly review the information and the time involved to accomplish this prior to an office visit.Discussion: Despite satisfaction among patients, portal adoption is still low, due totechnological limitations and to the lack of adaptability to primary care practice workflow. Notwithstanding those barriers, the use of the portal for completion of repetitive tasks, such as screening tools, should be encouraged.Conclusions: Patients can effectively use portals to complete the patient reported section of the CMS AWV. However, if the information is not completed during the same day of the office visit, the time required to address health findings outside of a regular office visit is uncompensated, and diminished the enthusiasm for this process among primary care practice staff.

Red spruce ( Picea rubens Sarg.) and balsam fir ( Abies balsamea (L.) Mill.) are sympatric in much of the Acadian Forest, but their relative regeneration success during the changing climates of the Holocene and after harvest in the modern forest has been distinctly different. Early life stage behavior may contribute to these differences. We report that seed germination by red spruce was equally fast and complete in warm and cool temperature regimes, while balsam fir germination was slower and less complete in both, especially the cool regime. Also, seedling shoot growth of red spruce exhibited a highly plastic response to increased light and water by maintaining continuous neoformed growth throughout the growing season, while balsam fir seedlings set bud after very little epicotyl development. Therefore, the root/shoot ratio of balsam fir was about twice that of red spruce, regardless of available light or water. Neoformed shoot growth under conditions of ample moisture and light would give red spruce a competitive advantage, but the relatively high root/shoot ratio of balsam fir seedlings would lower the likelihood that water and (or) mineral nutrients would limit shoot growth. The effects of these and other differences in life stage behavior on species abundance over time are discussed.

Environmental or occupational exposure to low doses of arsenic induces a series of health problems including cancer. The molecular events in arsenic-induced carcinogenicity remain to be defined. In the NuLi-1 immortalized human lung epithelial cell line with p53 and pRb deficiency, exposure to low doses of arsenic trioxide for 72 h promoted cell proliferation and upregulated the gene transcription levels of FOXM1, CDC6, CDC25A, and cyclin D1, which are both critical cell cycle regulatory genes and proto-oncogenes. Continuous in vitro exposure to 1 µM arsenic trioxide for 34 wks induced malignant cell transformation, as evidenced by enhanced anchorage-independent cell growth. The expression of FOXM1, CDC6, CDC25A, and Cyclin D1 was dynamically elevated at the gene transcription and protein levels in the process of cell transformation. The carcinogenic ability of transformed cell colonies coincides with the expression levels of FOXM1 in in vitro anchorage-independent growth assays and in vivo tumor xenograft formation assays. In reverse, the knockdown of FOXM1 in lung adenocarcinoma A549 cells or arsenic-transformed NuLi-1 cells significantly decreased anchorage-independent cell growth and tumor xenograft formation. The transformed NuLi-1 cells showed genomic instability in the form of copy number variation (CNV) at chromosome 1, 5, 6, 18, and 20, but not loss of heterozygosity (LOH). These results showed for the first time that chronic exposure to low doses of arsenic trioxide promoted lung carcinogenicity, in part by aberrantly upregulating FOXM1 and its associated oncogenes, when the tumor suppressor genes p53 and pRb were inactivated.

BACKGROUND: Patient blood management (PBM) programs are associated with reduced transfusion usage, reduced hospital costs, and improved patient outcomes. The application of PBM principles in patients with malignant disease might achieve similar results. However, this population presents unique challenges. The aim of the present study was to investigate the impact of a PBM program on blood usage and patient outcomes in cancer patients, particularly in the setting of restricted use of erythropoiesis-stimulating agents (ESAs). MATERIALS AND METHODS: A retrospective observational study was performed of patients admitted with a primary diagnosis of malignancy treated at Eastern Maine Medical Center as inpatients or outpatients, or both, from January 2008 through July 2013. RESULTS: The proportion of inpatients and outpatients receiving ESAs decreased from 2.9% in 2008 to 1.1% in 2013 (p < .001). During the same period, an increase occurred in the mean dose of intravenous (IV) iron from 447 mg (95% confidence interval [CI], 337-556) to 588 mg (95% CI, 458-718). The mean red blood cell (RBC) units transfused per inpatient and outpatient episode decreased from 0.067 to 0.038 unit (p < .001). In inpatients, significant increases occurred in the proportion of single-unit RBC transfusions (p < .001) and patients infused with IV iron (p = .02), and significant decreases in the mean pretransfusion hemoglobin (p = .02) and RBC transfusion rate (p = .04). In-hospital mortality and length of stay did not change significantly during this period. CONCLUSION: Despite the decreased use of ESA therapy, the implementation of a PBM program and outpatient anemia management protocol in cancer patients at our medical center was associated with significant reductions in RBC usage.

A chronic obstructive pulmonary disease (COPD) project was initiated at 18 primary care clinical practices located in rural areas of northeastern Maine to improve the diagnosis and treatment of patients with COPD through the adoption of evidence-based and best practice clinical guidelines for care management. Clinical guidelines based on the Global Initiative for Chronic Obstructive Lung Disease (GOLD) were implemented by the practices using the Institute for Healthcare Improvement Breakthrough Series learning session model. Practice barriers and patient barriers were identified through focus groups and were then addressed at the learning sessions and through direct contact with the practices. To evaluate the improvements that were a result of the project, changes in clinical practice and patient care were measured pre and post initiative. The greatest improvements in COPD patient care were in the areas of smoking cessation counseling, annual influenza vaccinations, discussion of self-management goals, and diet/exercise counseling. Participants reported that the collaborative nature of the project allowed for mutual learning, provided teams with support to identify and overcome barriers, and fostered teamwork to find solutions to shared problems.

Care management aims to provide cost-effective, coordinated, non-duplicative care to improve care quality, population health, and reduce costs. The 17 communities receiving funding from the Office of the National Coordinator for Health Information Technology through the Beacon Community Cooperative Agreement Program are leaders in building and strengthening their health information technology (health IT) infrastructure to provide more effective and efficient care management. This article profiles 6 Beacon Communities' health IT-enabled care management programs, highlighting the influence of local context on program strategy and design, and describing challenges, lessons learned, and policy implications for care delivery and payment reform. The unique needs (eg, disease burden, demographics), community partnerships, and existing resources and infrastructure all exerted significant influence on the overall priorities and design of each community's care management program. Though each Beacon Community needed to engage in a similar set of care management tasks--including patient identification, stratification, and prioritization; intervention; patient engagement; and evaluation--the contextual factors helped shape the specific strategies and tools used to carry out these tasks and achieve their objectives. Although providers across the country are striving to deliver standardized, high-quality care, the diverse contexts in which this care is delivered significantly influence the priorities, strategies, and design of community-based care management interventions. Gaps and challenges in implementing effective community-based care management programs include: optimizing allocation of care management services; lack of available technology tailored to care management needs; lack of standards and interoperability; integrating care management into care settings; evaluating impact; and funding and sustainability.

Abstract Limited knowledge of bird microbiome in the all‐body niche hinders our understanding of host–microbial relationships and animal health. Here, we characterized the microbial composition of the crested ibis from 13 body sites, representing the cloaca, oral, feather and skin habitats, and explored assembly mechanism structuring the bacterial community of the four habitats respectively. The bacterial community characteristics were distinct among the four habitats. The skin harboured the highest alpha diversity and most diverse functions, followed by feather, oral and cloaca. Individual‐specific features were observed when the skin and feathers were concentrated independently. Skin and feather samples of multiple body sites from the same individual were more similar than those from different individuals. Although a significant proportion of the microbiota in the host (85.7%–96.5%) was not derived from the environmental microbiome, as body sites became more exposed to the environment, the relative importance of neutral processes (random drift or dispersal) increased. Neutral processes were the most important contributor in shaping the feather microbiome communities ( R 2 = .859). A higher percentage of taxa (29.3%) on the skin were selected by hosts compared to taxa on other body habitats. This study demonstrated that niche speciation and partial neutral processes, rather than environmental sources, contribute to microbiome variation in the crested ibis. These results enhance our knowledge of baseline microbial diversity in birds and will aid health management in crested ibises in the future.

Mantle cell lymphoma (MCL) presents a therapeutic challenge. The B cell targeting agent, ibrutinib, is currently one of the most effective second-line therapies for MCL, but frequently leads to development of drug resistance, and short overall survival time upon relapse. Olaparib targets tumor cells with deficiencies in single-strand DNA break repair and thus may slow the development of genetic drug resistance. We found that the olaparib-ibrutinib combination significantly inhibits cell culture growth compared to either drug alone in two genetically distinct MCL cell lines. Moreover, these inhibitory effects are either additive or synergistic, depending on genetic background. Culture growth is inhibited due to increases in apoptosis, cell death, and cell cycle arrest, and the magnitude of each is cell line dependent. The additive and synergistic inhibition of this combination additionally supports a therapeutic strategy involving lower dosing of each drug to reduce potential side effects.

Here I summarize John A. "Tony" Nevin's evolution as a translational author. All of his publications were classified by title and content as being primarily experimental analysis of behavior or translational. Translational works were subtyped as interpretative, descriptive research, or experimental research. During the first 20 years of his publication career, Tony published exclusively experimental analysis of behavior work. In 1982, he began a series of interpretative translational analyses on topics of significant social importance. These interpretative papers translated behavioral science into logical accounts of issues of war and peace, for example, and performed quantitative analyses of available data to show that social behavior, even at the level of the group or society, conforms to predictions based on established behavioral principles. Tony began experimental translational research in 1990, first to establish whether his analysis of behavioral momentum generalized to humans. Several experimental studies later addressed the persistence of clinically relevant behavior and treatment relapse. The objective descriptions of Tony's publication patterns are punctuated with anecdotes from our 32-year collaboration and friendship.

BACKGROUND: Assays of antigen expression on myeloid cells have an underlying premise that the assay integrates high purity gating of the leukocyte subpopulation in question. While CD45/side scatter (SSC) gating provides sufficient gating purity for qualitative assays of antigen expression; it is unsuitable for quantitative assays of antigen changes, especially monocytes. We have validated a monochromatic gating approach combining CD45 and CD64 labeled with the same fluorochrome that allows for high purity monocyte gating. METHODS: Twenty-five blood samples were stained using three different antibody combinations (CD45 FITC + CD163 PE; CD45 FITC + CD64 PE; CD45 FITC + CD64 FITC). Data analysis focused on the percentage of "monocytes" defined by the various antibody and SSC gating combinations. RESULTS: Percent monocyte recovered by monochromatic CD64 gating was not statistically different from two-color CD45 + CD64 or CD45 + CD163 gating. All three methods of immunologic monocyte identification yielded a 12.93%-15.15% reduction in the "monocyte" percentage compared to CD45/SSC gating. CONCLUSIONS: A monochromatic combination of CD45 and CD64 antibodies with scatter signals allows higher purity monocyte gating by flow cytometry (FC) compared to CD45/SSC gating. This approach allows for the development of a high resolution four-color assay, such as for detection of paroxysmal nocturnal hemoglobinuria, whereby a single four-color tube will allow simultaneous high purity monocyte (CD64+) and neutrophil (CD15+) analysis of both phosphatidylinositol (PI) linked protein expression and FLAER binding.

Nutritional assessment is essential for identifying patients who are at risk for developing malnutrition or who have existing nutritional disease. It also is essential for monitoring progress on nutritional therapy. As cost containment plays a major role in health care today, emphasis is placed on the ability of healthcare workers in all care settings to recognize and avert potentially costly nutrition-related problems. This article reviews clinical assessment and laboratory parameters, with particular emphasis on the subjective data used in nutritional assessment.

Health sciences librarians serve as uniquely trained reference librarians who specialize in the research and dissemination of medical and health information and are an important link to quality health information for patients and consumers. The authors describe how the landscape of health sciences librarianship is constantly changing as new technology emerges, along with librarians' roles within the healthcare system.

BACKGROUND: History supports the staff and single serpent, the asklepian, as the symbol of healing and medicine, yet its confusion with the caduceus (a winged staff with two snakes wrapped around it) persists. No population-based information on serpent symbol use exists. OBJECTIVE: To determine the prevalence of asklepian and caduceus display among Internet images of medical and health professional schools' emblems, and to compare asklepian and caduceus display between medical and health professional schools, examining the effects of school longevity and geographic location on symbol display. METHODS: This cross-sectional survey examined Internet websites and Google Images associated with medical and other health professional schools in the United States, Puerto Rico, and Canada from 2013 to 2015. The primary outcome was display of a traditional or variant asklepian or caduceus among current and past emblems in Google Images. Odds ratios (ORs) and 95% confidence intervals for the comparison of medical versus other health professional schools were calculated by logistic regression. Differences among schools' longevity were assessed with Student's t-tests and linear regression. RESULTS: Among images of current and past emblems of 482 schools-159 medical schools and 323 health professional schools-107 (22.2%) emblems displayed only the traditional, and 205 (42.5%) any, asklepian. Adjusting for geographic region and longevity, medical schools were 59% less likely than health professional schools to display the traditional asklepian (OR 0.41, 95% CI 0.24-0.71, P=.001), and were 7.7 times more likely than health professional schools to display the traditional caduceus. Medical schools were 8% less likely than health professional schools to display any asklepian (OR 0.92, 95% CI 0.62-1.38, P=.70), and were 3.3 times more likely than health professional schools to display any caduceus. CONCLUSIONS: Schools' preference of the asklepian over the caduceus confirmed historical origins. Less asklepian and more caduceus display by medical schools suggests an educational opportunity for the medical profession to define for itself and the public the correct symbol of an interdisciplinary mission of healing.

The United States' healthcare model is in a serious period of change and redirection. This era holds the potential for transformations equal in significance to the introduction of prospective payment system or even the initiation of Medicare. This article describes the considerable and unique role that hospital and health system CEOs must play to position their organizations to not only survive but lead the transformation journey, with particular emphasis on the information technology investment imperative. Healthcare delivery is a multidimensional, multidisciplinary, and matrixed model. Change is hard. Information technology is evolving. Add these together and we begin to see the challenges ahead.

As hospitals and health systems pursue the work of transforming the delivery and payment models of the U.S. healthcare system, the findings presented in this article should provide additional impetus to explore community alliances that complement traditional patient care offerings. Utilization of community-based social, educational, faith-based, and care resources that are not part of a hospital or health system's collection of departments and services will allow the organization to extend the influence of provider-centric care models and engage broad communities of interest in a common mission of transformation. As stated by the authors, “This exploration is based on the realization that achieving high quality could involve factors outside the walls of the hospital.” At Eastern Maine Healthcare Systems (EMHS), our participation in the three-year federal Beacon Community Cooperative Agreement demonstration project (a collection of 17 national participants aimed at testing innovative models of care for those living with chronic illnesses) allowed us to demonstrate that collaborative approaches can lead to synergistic results. Collaboration and community connectivity extending beyond the hospital or health system can produce effective system redesign. For example, when a pediatrician's office engages public health nursing resources to provide home visits, a child's asthmatic symptoms can be better controlled. When a community care team partners to connect the social services of the local Agency on Aging with the acute care management plan, a socially isolated senior's anxietyproducing patterns of daily living are identified and emergency department/ambulance services utilization are reduced. The American Hospital Association has recognized the importance of EMHS's Beacon Community work by awarding the project a NOVA Award for 2013. The hypothesis as presented in this article, and confirmed through the research, demonstrates the need to consider all of the resources of any given community when going about the work of accomplishing the Institute for Healthcare Improvement's Triple Aim: improving the care experience for any given individual, transforming the approach to population health management, and reducing the overall cost of care delivery. The authors present data to support a strong community relations orientation for hospitals and health systems. As we move toward a healthcare delivery and reimbursement model that is value based (rather than volume oriented), we must establish solid and comprehensive community relationships with nontraditional partners who share providers' interests in the health and well-being of their communities. By engaging communities of interest to create new models of care delivery, the greatest impact can be made. Success might be more likely if state and national associations representing these stakeholders (schools, Chambers of Commerce, professional societies, health departments, etc.) would identify common priorities and engage their broad memberships in focused initiatives. A logical place to start would be with those who can affect the care of people living with chronic illnesses and the populations at highest risk—for example, overweight youth—because they are at the axis point where transformation and health economic modifications are the greatest. The eight components of the community orientation scale, as outlined in this article, provide an effective framework for planning and performance management.