Problem: Health care systems, especially acute care settings, are becoming overburdened with patients who are older, have medical complexity, and have limited access to health care resources. Community paramedicine (CP) programs use paramedics to offer preventive care, health education, and connections with the community that is underserved and experiencing homelessness. CP programs have emerged to reduce acute care utilization and emergency department visits, and to improve health care outcomes. Approach: A local CP team was paired with the MaineHealth cardiovascular disease fellows' clinic to expand cardiovascular care to patients at high risk. Individuals were identified by clinicians as requiring additional support and were referred for home visits with the CP team. Information collected included patient demographics, medical history, reason for the encounter, psychosocial barriers to care, emergency department visits, and medication discrepancies. A descriptive analysis was then completed to characterize the patient population, describe services provided, and evaluate the impact on patient health care utilization. Outcomes: Over 1 year, the CP program visited 156 patients with a median age of 70 years. Patients often had multiple reasons for a visit, including medication management and reconciliation (65%); vital sign measurement, such as blood pressure measurement (85%); and clinical assessment for heart failure (45%). The most common cardiac conditions encountered were diastolic and systolic heart failure (60%). Common social barriers to care included lack of transportation, language barriers, food insecurities, and unstable housing or homelessness. The CP program facilitated wearable cardiac rhythm monitors, phlebotomy collection, wound checks, and health education. Next Steps: CP programs are an additional resource to cardiovascular care beyond the traditional clinic setting and may help address medical and social barriers in patients at high risk. Further research must be completed to analyze the long-term impact and safety of CP programs on patient care and hospitalizations.
Problem: The objective of this project was to evaluate and describe the flow of patients who have delayed discharge after they have participated in an enhanced therapy program. Approach: In the current practice, which started in 2021, the care coordination team identifies patients medically ready for discharge but with barriers. Working with the rehabilitation team, the care coordination team determines if the patient is suitable for the enhanced therapy program. These patients go on to receive 1 hour of physical therapy and 1 hour of occupational therapy each day, Monday through Friday, with the goal of discharge to home. Outcomes: The evaluation of this program focused on the length of stay, discharge destination, and number of days in the enhanced therapy program. Next Steps: The evaluation will use anonymous data collected as part of the standard practice in care coordination.
Problem: Homelessness is prevalent in Maine and throughout the United States. People experiencing homelessness have unique medical needs that require both primary and subspecialist care, but they face barriers to accessing these services. Infectious diseases, including HIV, viral hepatitis, and skin and soft tissue infections, are highly morbid but are preventable and treatable. Thus, access to infectious disease subspecialty care is a high-impact target for improving the health of people experiencing homelessness. Particularly given Maine's HIV outbreak, there is an urgent need to reduce barriers to accessing infectious disease care. Approach: In January 2022, a monthly, half-day infectious disease subspecialty satellite clinic was established at an existing free-standing, low-barrier clinic in Portland, Maine, for people experiencing housing instability. Appointments were scheduled, and walk-in appointments were also available. An infectious disease physician and fellow provided care in collaboration with clinic staff and pharmacy support. Here, we describe the demographics, clinical characteristics, and health outcomes of patients seen in this low-barrier infectious disease clinic. We also compare no-show rates at the clinic and other local infectious disease clinics. Outcomes: Thirty-four patients received infectious disease care at the low-barrier clinic between January 2022 and June 2025. Of these 34 patients, 30 (88%) were experiencing homelessness. All patients (100%) had a history of substance use. The most commonly treated conditions were hepatitis C (17 [50%]) and skin and soft tissue infections (15 [44%]). No-show rates were lower at the low-barrier infectious disease clinic (42%) than at 2 nearby infectious disease practices (70% and 62%). Next Steps: Here we show a proof-of-concept for low-barrier infectious disease care as a feasible approach to caring for people experiencing homelessness. Lower no-show rates suggest potential for greater cost-savings with investment in low-barrier subspecialty care. Further research is needed to better elucidate these secondary benefits and specific drivers.
Problem: Inadequate patient work capacity documentation by clinicians contributes to health and economic inequity, clinical inefficiency, and worse patient health outcomes. The intersection of an aging workforce and high amounts of work disability presents an opportunity for health systems to integrate occupational health best practices across clinical settings to improve patient health and work outcomes. Clinicians, however, are often unfamiliar with navigating patient work capacity forms to help patients maintain or obtain employment. This knowledge gap further perpetuates work disability. Approach: To compensate for this gap, we co-created a training for clinicians that integrates didactic learning and supplemental resources to support clinicians in accurately and efficiently completing work capacity forms. We recruited clinicians who volunteered to be a part of the training. Pre-training and post-training surveys were used to evaluate the training. Outcomes: In the preliminary study, 32 participants completed the pre-training survey and 22 completed the post-training survey. More than half (59.2%) of the participants felt that they do not have enough information or guidance when filling out patient work capacity forms, and only 16.7% reported having previous training. In both surveys, participants were asked a series of questions that assessed their confidence with work capacity forms. After the training, there was a statistically significant difference in confidence across all 4 domains: ``Completes work capacity forms accurately,'' (P < 0.044), ``Determines appropriate work modifications for patients,'' (P < 0.001), ``Discusses employment goals with patients'' (P < 0.001), and ``Connects patients to appropriate work and health resources,'' (P < 0.005). Next Steps: Our interprofessional intervention initiative seeks to engage and educate clinicians across specialties with information and effective strategies to improve patient employment support and completion of work capacity forms. The co-design team will use the survey feedback to refine the program with the goal of reducing patient work disability. By improving confidence and competency in this process, clinicians can promote a healthier, inclusive workforce environment through patient care.
Problem Statement: Artificial intelligence (AI) tools are routinely used by residents and fellows across graduate medical education. The Accreditation Council for Graduate Medical Education has no AI-specific policy nor requirement for disclosure norms, leaving programs and attending physicians without a standard framework for supervising AI-assisted trainee work. The result is a training environment in which AI use is simultaneously widespread and under-governed by operating without the policies and supervisory frameworks needed to make that use educationally productive. Background: AI tools are now embedded across health system workflows, and their use has expanded beyond clinical documentation into education, research, and scholarly work. At MaineHealth, a gap became visible: as AI entered our clinical environment through institutional platforms and trainee-driven adoption alike, our program found itself without a shared framework for discussing, supervising, or teaching around its use. Application: Drawing on a structured debate at the Roux Institute at Northeastern University and the emerging graduate medical education literature on AI supervision, we propose a practical governance framework for AI use in residency and fellowship training. The framework synthesizes current evidence and existing supervisory structures to offer guidance across 4 domains: task-level expectations for trainees, real-time supervision strategies for attending physicians, integration of AI literacy into existing didactic structures, and program-level governance principles. AI literacy is a core professional competency, not optional enrichment. We must address not whether to engage with AI, but how, and in ways that preserve learning and build habits appropriate for AI-enabled practice.
Introduction: Primary headache associated with sexual activity (PHASA) is an uncommon but benign headache disorder that may mimic life-threatening causes of thunderclap headache. Careful diagnostic evaluation is essential at first presentation. Clinical Findings: Two women aged 40 and 42 years presented in a family medicine setting with abrupt-onset headaches that occurred exclusively during sexual activity and strenuous exercise. Findings from the neurologic examinations were normal in both cases. Brain magnetic resonance imaging with and without contrast showed no acute abnormalities. Clinical Course: Neither patient underwent lumbar puncture or vascular imaging. Both were treated with pre-emptive therapy using indomethacin or triptans, and both reported symptom improvement without neurologic complications at follow-up. Conclusions: These cases illustrate probable PHASA in women who present to outpatient primary care. Although typically benign, first-onset headaches during sexual activity require exclusion of secondary causes. Recognition of PHASA allows for appropriate reassurance, pre-emptive therapy, and patient counseling while acknowledging diagnostic limitations.
Introduction: Primary central nervous system vasculitis (PCNSV) of small vessels is an exceedingly rare presentation of vasculitis. Diagnosis typically takes many months, requires multiple diagnostic modalities, and includes a positive biopsy in less than 50% of cases. We present a unique case of PCNSV that will help clinicians identify this rare disease. Clinical Findings: A man in his 60s presented with confusion and aphasia and was found to have a parietotemporal brain mass. The mass was heterogenous, with inflammatory, cystic, necrotic, and hemorrhagic components. Two separate brain biopsies underwent review at 3 institutions before the diagnosis was made. Clinical Course: The patient was initially treated with steroids, amphotericin B, and flucytosine due to concern for cryptococcus on initial biopsy. After a negative universal polymerase chain reaction and repeat biopsy, he was treated with prednisone, cyclophosphamide, and methotrexate without significant improvement. He died in hospice 4 months after initial presentation. Conclusions: Diagnosing PCNSV can be extremely difficult due to sampling error in biopsy tissue and a lack of systemic markers. We review PCNSV and its epidemiology, diagnosis, and treatment.
Introduction: We investigated the characteristics and contributing factors of overdose fatalities associated with kratom by examining descriptive data and toxicology findings from medical examiners in select New England states. Methods: We contacted medical examiner offices in 6 New England states to request forensic data on overdose deaths attributed to kratom from January 2015 through July 2024. Primary outcomes were postmortem toxicology and autopsy findings, and secondary outcomes were descriptive case details. Results: In 2 cases for which toxicology findings were available, concurrent substances were detected in the deceased individuals. Postmortem mitragynine amounts were 890 ng/mL and 23 ng/mL. Autopsy findings revealed no significant abnormalities. A third case was identified; however, the only detail disclosed was a history of atherosclerotic cardiovascular disease. Discussion: The findings revealed that fatalities often involve polysubstance co-ingestions or underlying conditions, with kratom's contribution remaining complex and multifactorial. Limitations included a small sample size, variability in toxicology testing, and incomplete data. Conclusions: Rigorous standardized protocols are needed to elucidate kratom's role in overdose deaths.
Introduction: Patients with anorexia nervosa have a mortality rate more than 5 times higher than the general population. Medical stabilization through nutritional rehabilitation is essential, yet institutional practices vary widely. Nasogastric tube (NGT) feeding has been the standard in pediatric inpatient settings, despite evidence suggesting similar outcomes with oral refeeding and potential for psychological trauma. Methods: An interdisciplinary work group representing adolescent medicine, pediatrics, nursing, nutrition, psychiatry, and social work developed a standardized, evidence-based pediatric nutritional rehabilitation protocol. Existing clinical pathways from other institutions were reviewed, and the protocol was adapted for existing resources. Educational modules and a protocol-specific order set were implemented. Pre-implementation and post-implementation data were collected via chart review to evaluate key outcomes, including NGT use, weight gain, refeeding complications, and disposition. Results: A total of 46 patients were included (22 pre-implementation, 24 post-implementation). NGT use decreased from 100% to 16.7% after implementation. No patients developed clinically significant refeeding syndrome. There were no significant differences in average weight gain or length of stay between groups. Discussion: Implementation of a standardized interdisciplinary protocol reduced reliance on NGT feeding without compromising medical outcomes. Oral refeeding proved safe and effective when guided by a consistent, evidence-based approach that integrated behavioral health. Reduced NGT use facilitated psychiatric placement and minimized hospitalization-related trauma. Conclusions: A structured, interdisciplinary nutritional rehabilitation protocol can achieve medical stabilization in pediatric patients with anorexia nervosa while reducing invasive procedures. Standardization of care and emphasis on oral refeeding are important steps toward trauma-informed, evidence-based treatment of eating disorders.
Introduction: Sydenham chorea is the most common parainfectious chorea in children and may be the only presenting symptom of acute rheumatic fever in children. However, choreiform movement disorders in children may also be the result of nonspecific immune processes or other non-immune-mediated disorders. We present the case of an otherwise healthy 10-year-old girl with a nonspecific immune-mediated chorea that resolved with immunomodulatory therapy. Clinical Findings: The patient's exam results indicated orolingual dyskinesia and blepharospasm. The patient had intermittent choreiform movements of the neck, trunk, and extremities (including a ``milk maid's grasp'') that persisted even when she was asleep. Her coordination was impaired due to chorea and included dysmetria and dysgraphia. Her laboratory results were positive for immunoglobulin G and immunoglobulin M of Mycoplasma pneumoniae antibodies, anti-streptolysin O, anti-DNAse B titers, anti-thyroid peroxidase, and anti-glutamate decarboxylase-65 antibodies. Her erythrocyte sedimentation rate was also elevated at presentation. Clinical Course: The patient's symptoms did not improve with low-dose risperidone or empiric treatment for both Strep pyogenes and Mycoplasma pneumoniae. Her dyskinetic movements also did not improve with time and persisted for 17 days after her initial discharge. She was subsequently readmitted to the hospital and treated with high-dose methylprednisolone and intravenous immunoglobulin, which resulted in long-term resolution of her dyskinetic movements. Conclusions: Immune-mediated choreiform movement disorders may be nonspecific and involve etiologies other than Sydenham chorea/acute rheumatic fever. Empiric immunomodulation should be considered for other autoimmune or parainfectious etiologies of chorea in childhood.
Introduction: Pneumonia readmissions are a persistent challenge for health care providers and patients. Although the mortality risk associated with hospitalization for pneumonia is well-known, the particular risk associated with readmission for pneumonia is not as well characterized. Methods: We retrospectively examined our institution’s electronic health record to determine the 270-day mortality rate for patients readmitted after an index hospitalization for pneumonia. Results: At our institution, we found a substantial mortality risk associated with 30-day pneumonia readmissions, with variability between the 2 studied sites of care. Discussion: Various factors could contribute to high mortality associated with 30-day pneumonia readmissions. Conclusion: Additional study of the mortality rate associated with 30-day pneumonia readmissions is indicated, both locally and nationally.
Problem: Overdose deaths and rising rates of infectious disease in the state of Maine warrant a strong public health response, overdose prevention education, and interventions. Initiatives for community drug checking are an innovative approach to understanding the composition of the current drug supply. Drug-checking initiatives can inform people who use drugs (PWUD) what adulterants might be present in their drug supply. In partnership with 3 community organizations in Maine, Project DHARMA supports PWUD and community partners with infectious disease screening, community drug checking, and infection and overdose prevention. Approach: Project DHARMA supports the delivery of evidence-based infection and overdose prevention strategies across the state by funding outreach specialists embedded in community organizations. The outreach specialists work with PWUD to provide education, supplies, and linkage to care for infectious disease prevention and treatment, wound care, and substance use treatment. Outcomes: Over 3 years (2022-2025), outreach specialists distributed 61295 fentanyl test strips, tested 1644 people for HIV, trained 10193 people on how to use naloxone, and provided overdose education to 9417 people. We sent 82 samples for Fourier transform infrared spectroscopy testing for our community drug-supply initiatives. We partnered with universities for technical assistance to inform our drug-checking protocols and provide training to students in the health professions, and 312 students and providers in infection and overdose prevention. Next Steps: The Project DHARMA team will continue to track testing and screening rates for infectious diseases, collecting data to inform initiatives, and examining drug-checking trends throughout Maine. With funding from Maine’s opioid settlement funds, we will continue this work with community partners and outreach specialists. With additional funding, we are exploring the feasibility and acceptability of drug-checking programs. This work will inform how to best deliver drug-checking results to PWUD.
Introduction:Cannabis and cannabinoid use in patients with cancer has rapidly scaled up over the past decade and is a topic of considerable clinical, research, and public health interest. Methods:We conducted a cannabis landscape survey among front-line providers in the MaineHealth Cancer Care Network (MHCCN) before applying and participating in National Cancer Institute (NCI)-sponsored studies on cannabis use in patients with cancer. The results of the survey can better inform participation in national studies and provide a departure point for provider educational activities focused on cannabis use in the cancer care setting. Results:Notable observations from our survey included a 58% (100/171) response rate, which signals awareness and interest in cannabis use by our provider teams. Also, 30% of providers/care team members inquire about their patients' cannabis use, 89% agree that cannabis can be effective for managing symptoms, 54% are sensitive to stigma surrounding cannabis use (as well as 57% of their patients), only 15% considered themselves knowledgeable, and 85% are receptive to learning more about cannabis use. Discussion:These observations confirmed interest among our care teams to engage in cannabis-focused studies. They also paved a way toward participating in NCI-sponsored studies to address gaps in knowledge and the benefits and harms of cannabis and cannabinoid use in patients with cancer. Barriers and themes from the survey related to conducting research in this therapeutic area are discussed. Conclusions:Longitudinal studies evaluating the benefits and harms of cannabis use remain scarce. Significant gaps in knowledge persist for both providers and patients, compounded by regulatory, ethical, and drug provision hurdles in this research area. Our survey results offer a foundation for educating care team members about cannabis use. Alongside participation in a large, first-ever national study, we outline plans for a small pilot study that uses an innovative application to capture cannabis use and product type.
Abstract Each year one in four older adults has a fall1 and only about half tell their doctor or healthcare provider2. One way to prevent falls is to provide older adults with the evidence-based tools to prevent them. A Matter of Balance: Managing Concerns about Falls (MOB), is a top tier program for grant funding from the Administration for Community Living Falls Prevention Program. MOB has been shown to reduce the fear of falling and increase activity levels among older adults through cognitive restructuring and balance exercises.8 Prior to 2020, MOB was only offered as an in-person, small group (8-12 participants), community based intervention over 8 two-hour sessions led by 2 volunteer facilitators. In response to the global COVID-19 pandemic, MaineHealth’s Partnership for Healthy Aging adapted the Lay Leader model of MOB for virtual delivery (MOB-V). Review of MOB-V pilot data suggested that it was also effective in reducing the fear of falling and increasing the activity levels of older adults. Based on this success, the MOB-V was more widely disseminated during 2021 and 2022, but to date no comprehensive program evaluation of the MOB-V has been completed. We will present the preliminary results of our evaluation of participant data collected from the National Falls Prevention database between 2021 through 2022.
Introduction: Bartonella species are notable causes of culture-negative endocarditis, particularly in patients with prosthetic valves or congenital heart disease. These infections can present insidiously, mimicking other systemic illnesses and posing considerable diagnostic challenges due to their fastidious nature. Clinical Findings: A person in their 30’s with repaired tetralogy of Fallot and a Melody pulmonary valve presented with acute biventricular heart failure, nephrotic-range proteinuria, and pancytopenia. Initial assessments suggested cardiorenal syndrome. Despite negative routine cultures, persistent renal abnormalities and hypocomplementemia raised suspicion for glomerulonephritis. Subsequent polymerase chain reaction analysis of blood returned positive for Bartonella henselae, and positron emission tomography-computed tomography revealed focal uptake at the Melody valve, confirming prosthetic valve endocarditis. Clinical Course: The patient received aggressive diuresis, targeted antibiotic therapy with intravenous doxycycline and rifampin (later changed to ceftriaxone due to hepatoxicity) and multidisciplinary supportive care for multisystem organ dysfunction. Despite showing some clinical improvement over 32 days of hospitalization, the patient elected for self-directed discharge. Conclusions: This case illustrates the diagnostic difficulty of Bartonella endocarditis when it manifests with a complex triad of heart failure, nephrotic syndrome, and pancytopenia. The presentation can delay diagnosis by mimicking non-infectious systemic disorders. The utility of specific molecular diagnostics and advanced imaging is crucial in such culture-negative scenarios. Bartonella infection warrants consideration in patients with prosthetic cardiac materials who develop unexplained multisystem dysfunction.
