IORA CHAPTER SIX ASKS Jennie, Tracy, Kathleen and Rushika If you led a group class at the 2018 Leadership offsite for patients, what would I STARTED MY JOURNEY WITH IORA on February 24, 2020. 12 the topic be? business days later, on March 11, 2020, we learned that Iora would be closing the Nest indefinitely due to the COVID-19 Iora is so much more than a doctor’s office, as we build pandemic. I was just starting to learn everyone’s names and to communities for the health and wellbeing of our patients get to know my fellow team members, exploring the rhythm and beyond! The top 3 areas our teams chose for groups and the culture of Iora. Fortunately, the Marketing team at Iora is solid gold, and they would lead are: our leaders at the time were really keyed in to keeping every- one connected and in good spirits during this challenging time. 01 Exercise Spear-headed by Kathleen Haley and Rebecca Chaveriat, the Mar- keting team met daily to connect not only about the work we were We heard lots of responses for all doing to support our care teams and patients, but to have fun! exercise. Everything from chair Every meeting, someone would volunteer to either come hip hop to swimming. up with a costume theme, questions to discuss, or an activity that our entire team would participate in. We talked about who 02 Mental Health we’d want to be quarantined on an island with, what shows we & Mindfulness were binge-watching, dressed up as characters from The Office, showed our school spirit and escaped on virtual tropical vacations Including “Giving Yourself together. As a new employee, I really valued these fun get togeth- Grace in 2020”. ers because they allowed me to still get to know my team infor- mally, even if I couldn’t see them in-person. 03 Cooking MERCEDEZ Including the awesome combo of music & cooking. Associate, Digital Marketing | Nest 49
MOMENTS THAT MATTER FROM CLASSES AND EVENTS Exercise class in Iora’s group room I have never felt like a primary care physician office cared as much as Iora. I had never experienced a Health Coach before, it was great. Iora offers so many classes and/or workshops all for free. —TUCSON PATIENT 50
CHAPTER SIX Chair yoga! HUMANA HOSTED A “Vietnam Veteran Pinning Ceremony” event THE PATIENT AMBASSADOR COMMITTEE (PAC) meetings were at our Broadway practice, and due to the turnout we ended up incredibly memorable because we were able to connect with hosting the event in the parking lot outside of our practice under our patients and learn about them. We also got to dive deep a white tent with plenty of tables and chairs. With the last min- and understand what they love about Iora, but also our ar- ute switch to host it outside, the event rental company needed eas of opportunity. After our last PAC meeting of the season, to drop off 200 folding chairs the day prior, so a few dedicated we got together and brought in a cake, some balloons and Iorans showed up early to unwrap, unfold, and move 200 chairs certificates to thank all the ambassadors for being part of our from our group room to the tented parking lot. It was such a journey. There are too many memories to count, but so many great example of teamwork in unexpected situations. The event of the conversations had during these meetings will stay with was very memorable, and Humana was able to pin 26 veterans! me forever. MILLIE PRISCILLA Manager, Communications & Patient Experience | Nest Marketing Specialist | Nest 51
THE IMPORTANT ROLE OF CAREGIVERS 07 The Important Role of Caregivers 52
CHAPTER SEVEN WE HAD A PATIENT that was suffering from multiple surgeries I WILL NEVER FORGET one of my long term patients and his son. and complications as a result of Ameloblastoma. The patient When I joined Iora in 2015, Scott also joined Iora. He had been and his wonderful spouse were driving back and forth from my patient for 15 years, and we had our ups and downs, but we Arizona to California for his healthcare. In all the appointments grew fond of one another. Scott had multiple chronic condi- and phone calls that I had with these amazing human beings, tions and sustained a hip fracture. After the hip fracture, he took not once did I hear them complain. a turn for the worse with several complications and worsening The patient’s wife was on top of his care and made sure chronic conditions and could no longer care for himself. Scott’s she communicated regularly with me to ensure Iora was kept son, John, became his caregiver as the only living family mem- in the loop. As part of their care team, I grew very close to this ber. Scott had no other support system. patient and his lovely wife. He unfortunately lost his battle with One day, John walked into our office in tears, completely Ameloblastoma. That very same day, his wife came into the overwhelmed, as he didn’t know how to care for his father. Our practice to visit me and delivered a warm hug of gratitude as care team (provider, Health Coach, Behavioral Health Special- a thank you for being their support system through it all. She ist and Registered Nurse) assessed the situation, partnered with was so unbelievably grateful for the efforts and compassion Scott and his son to develop a comprehensive care plan and from their Iora care team. As a Health Coach with Iora, I could advanced directives. not have been more proud and grateful to have had the honor We helped John by connecting him with a caregiver support to care for them. group and classes on elder care. In addition, we partnered with Humana case management and Hospice Palliative Care. With MICHELE everybody on board, we were able to get community resources for John, which in turn, gave him the support and education he Health Coach | Phoenix needed to provide his father with a very comfortable end of life plan. Scott passed away in the comfort of his own home with his son at his side. John continues to keep in touch with us and reminds us of how Iora helped him during a challenging chapter in his life, and he has told us he will be forever grateful. CHARLOTTE Market Medical Director | Phoenix 53
THE IMPORTANT ROLE OF CAREGIVERS The whole staff is AMAZING. I am the caretaker for both of my parents and I honestly don’t think I would be able to keep my head on straight without the help of this team! The doctor is a blessing - she really cares. —GEORGIA CAREGIVER Brittany, Vanessa and Lindsi MY MOM AND I have recently relocated to Sun City West from 54 NYC. Besides dealing with the results of a cross country move, I was most concerned about contacting doctors. I hand carried most of the most important papers but where to start. Lucky for me as I passed Iora’s location it looked inviting and I stopped in. I instantly felt relieved in speaking with the consultant. I was so pleased that I contacted several of the doctors back in NY to let them know that my mom and me are well taken care of here in AZ. I am grateful for the response, concern and overall satisfaction with Iora. —PHOENIX CAREGIVER
CHAPTER SEVEN MY GREAT GRANDPARENTS were both very pleased with the service they received at Iora Primary Care. They felt that the doctor was very attentive to their wants and needs, and got the best care they have received in a long time. Thank you so much for keeping them feeling good and healthy. —GEORGIA CAREGIVER I GOT TO KNOW ONE of our patient’s daughters. She had a full The Dartmouth Health Connect team time career in healthcare. She was a mom to a teenager and a caregiver for both of her rapidly aging parents. Her mother had IT DOES MY HEART GOOD to take my dad to see the team at a stroke, and her father’s health was declining fast. Iora. I have felt so alone in caring for him as he deals with She was very businesslike and made sure our next steps for COPD, but I leave every interaction—office visits, phone calls, her mom were clear. She helped us hold her mom account- email, and even a home visit (!)—feeling like there is a plan in able to our after-visit instructions and followed up closely. I place to do the best we can for him and I am not alone. And it’s identified with her as someone who really had no choice but not about me, but dad also is constantly impressed and amazed to do it all. I was so impressed with how she gracefully handled by the knowledge, perseverance, and commitment of the team. everything. —WASHINGTON CAREGIVER One day after a visit, she pulled me aside. She was tearful and told me about how grateful she was for Iora and what we 55 do for her mom. She said, “This all would have been impossible without you guys doing what you do.” I was floored because from what I could see, she was amazing and really had all it together. A peek behind the curtain demonstrated how impactful our team approach at Iora can be. Those conversations around the Huddle table made a difference. JENALYN Care Team Manager | Tucson
THE IMPORTANT ROLE OF CAREGIVERS Emily at an agent fair “I was so inspired... it made me rethink the way I viewed my own aging parents and family.” WHEN I WAS A HEALTH COACH, I was overcome with the young Nikki and Sha caregivers I would encounter on a daily or monthly basis. One patient I worked with had dementia, and her son (who was younger than me), went to the ends of the earth to help her. He took time off of work, moved her from the other side of the country, arranged his days to help her with her daily activities - even his girlfriend stepped in and was involved in her care. I was so inspired by him, and it made me rethink the way I viewed my own aging parents and family. MACKENZIE Market Administrative Assistant | Phoenix 56
IORA CHAPTER SEVEN ASKS What is your favorite Iora team activity (in-person or remote)? We are a relationship-based organization, and our teams are an important part of this. The top two team activities are: Iora patients at a class at our practice 25% THIS IS MY DAD’S NEW PCP and I can say it’s the best doc- after work fun tor’s office I’ve been to. From new patient intake, front desk, nurses, the Health Coach, to the doctor, everyone was super like happy hours and holiday parties helpful, friendly, and seemed to want the best for my dad. Iora has a Health Coach for each patient which is very helpful as 14% they are the advocates for their patients to ensure proper care is received by documenting concerns, summarizing each visit, Huddle coordinating any referrals/authorizations, follow-ups, etc. My dad’s first visit was an HOUR long to get his medical back- Some got specific about the parts of Huddle ground and to get familiar with my dad as a new patient. I they like best such as wins and highlights: feel very comfortable with Iora being my dad’s PCP and highly recommend them to others for senior care. Plus they are con- “Highlights have always been my favorite, tracted with Medicare Humana so they are familiar with their it helps build the team mentality and policies and coverage. The facility looks new, is clean, and has boosts morale in the office. There have a comfortable environment. The Renton location is easily ac- been many special moments shared cessible with plenty of parking. between the teams during highlights, —WASHINGTON CAREGIVER sometimes even some tears.” 57
08 Memorable Patients 58
CHAPTER EIGHT “Knowing there are many BACK DURING THE 2016 Medicare Annual Enrollment more stories like my own Period (AEP), I had stayed late at the Shoreline practice and is a powerful motivator for was opening the door to leave when a car pulled up and the me every single day.” driver (I’ll call him “Bill”) said he had “just a few questions”, because he needed to find a doctor for his mom. I HAD A PATIENT come in who was caring for her husband. She Admittedly, I was tired and wanted to go home, but we was dealing with caregiver stress and burnout, plus a lack of self- connected immediately as we both helped our moms manage care. She was not being assertive in her relationships and felt their care, and I could tell from his tone and body language drained. We worked a lot on healthy boundaries, how to prevent how important this was to him. caregiver burnout, and self esteem. I disarmed the alarm, began the open-ended questions By the end of our treatment, she went from taking zero time that helped us understand more about the situation, and about for herself to golfing two hours each day and was able to encour- an hour later we shook hands after having scheduled a tour for age her husband to do more things that he was capable of, rather Bill and his mom with the Patient Enrollment Coordinator at than leaving things for her to do. Shoreline. When we finished our episode of care, the patient said: “I Fast forwarding to mid-2018, I walked into the Shoreline really appreciate everything you’ve done for me... you taught me practice to see Bill in the waiting room. He shared that he had how to take care of my mental health and how important it is...” chosen to become a patient as well, not just because of the I was humbled to be a part of her journey. One of my favorite care the team gave his mother, but also because of how the parts of being a Behavioral Health Specialist is helping patients team supported him and his family over the past few months to see their own innate worth and dignity and helping them take while she was in hospice, and through her passing. concrete steps in the direction of happiness. He said that the team felt like “ a family I didn’t know I had”, and he couldn’t imagine what the past two years would have HANNAH been like without the team at Iora. Why do I love this story so much? This happened just after Behavioral Health Specialis | North Carolina my mom had joined Iora. I knew the difference it would make for another son wanting the best care possible for his mother. Knowing there are many more stories like my own is a power- ful motivator for me every single day. KEVIN Senior Strategic Account Executive, National Distribution | Nest 59
MEMORABLE PATIENTS “Joe found some kind of peace in his last days. And I want to thank you for that.” A hand carved Iora bird from a patient NEARLY 10 YEARS AGO, I took on one of my hardest jobs at 60 Iora: Health Coach at the Culinary Extra Clinic in Las Vegas. Iora was a young company. We had just launched the Culinary and Dartmouth practices. I knew how to be a primary care doctor from years of practice. I had learned value-based care and how to work with Health Coaches in Atlantic City. But, I had never had a chance to truly live and learn the Health Coach role. We were building Iora in a new community, where I wasn’t known as Dr. Neil, so I became Health Coach Neil. And I was ready to learn. My most important lesson came from Joe. Joe was a skin- ny 78 year old man who came to his appointment wearing faded jeans, a giant belt buckle and the smell of cigarettes. He described himself as a “lifelong scumbag.” He told me how much he used to drink, how poorly he treated people and how anyone who knew him had left him. Joe had several chronic conditions, and his goal was to stop taking “too many damn medications.” Over several visits, he saw Dr. Schutzbank, Dr. Rushika, Dr. Snow, and Sarah the Behavioral Health Specialist, but I became his steady partner in care. I got to know his wife and son. Over time, we met his goal to stop nearly half of his meds. His gruff attitude softened. I learned what it was like to earn trust as a Health Coach. After two months of being his Health Coach, Joe revealed to me that he was experiencing abuse from his adult son. He
CHAPTER EIGHT did not share details. “I deserve it,” Joe insisted, for all of the What did I do wrong? abuse he had heaped onto the world. Thinking back, I realize My thoughts shifted when I realized that I should call Joe’s that Joe never named a goal to change this—maybe he only wife. I had to check on her. A new worry gripped me. What wanted me to know. As a motivated Health Coach, however, would I say? What would she say? Would she be upset? I had my own goal. I convinced him to meet with our Behav- I gathered myself and found a quiet consult room. I ioral Health Specialist. Sarah led a family meeting with his opened the shade to let in some sunlight. I called. Joe’s wife son and wife where Joe could safely confront his son about sounded well. Her voice was strong. She told me that Joe had his behavior. As a Health Coach, I felt like I was operating all died peacefully in the night. “He suffered so much in his life,” the levers, connecting Joe with all of the care he needed. On she told me, “but he didn’t suffer in the end. Neil, you know, the day of the meeting, however, Joe was silent. When asked Joe never slept well. Something changed after that family about abuse, he denied it. “No one’s abusing me. You guys meeting.” She explained, “We came home that day from the got it wrong.” While Dr. Neil was used to patients not follow- Culinary to the trailer and no one yelled. There was always ing the plan, Health Coach Neil was disappointed. What had I yelling, but that day, there was no yelling. No cursing. No done wrong? stomping around. They didn’t say much to each other, but it A few days later, my family and I left Las Vegas and was peaceful here for the first time ever. And it’s been that way returned home to New Jersey. My months in Vegas were up. The for the last few days. Joe had been sleeping, too. Joe found practice was in good hands. I flew home on a Saturday. I flew some kind of peace in his last days. And I want to thank you to New Hampshire on Sunday. On Monday morning I reported for that.” to Dartmouth, to help our other new practice. Everything felt I miss Joe. I never learned his whole back story. I still new on 7 Allen Street in Hanover, NH. After the Huddle, when I don’t know if we did everything right. But I know he trusted checked my email, I learned that Joe had passed away. me. And I know that trust was enough to help him to find What had happened? He was fine last week, I thought. what he was missing. Joe had stopped so many medications; he had felt better, but could one of those medicines have been needed? What was NEIL my role? As a Health Coach, I didn’t make any medical deci- sions, I left that to the licensed doctors, but should I have? Market Medical Director | Northeast 61
MEMORABLE PATIENTS Members of our Patient Ambassador Committee One of the first questions I asked Bob was, “Would you please tell me a funny story from your childhood?” BY THE THIRD TIME Bob was admitted to the hospital, I was Bob proceeded to tell me a story about growing up on a talking to all the subspecialists—surgery, GI, cardiology. And dairy farm, and the next day, I texted the story to his son, Tim. by the fourth admission, I intervened even more assertively in This initiated and influenced the depth and breadth of the true the hope of surgically correcting his anatomical problem. Un- spiritual friendship Bob, Tim and I had from that moment on. fortunately, he was too frail to consider the very invasive mea- It was no longer a doctor-patient-son relationship. Bob was sures that needed to be taken. He, his wife and his son opted the older, wiser, more experienced ship captain, sharing and for hospice care, which during the COVID-19 pandemic, left teaching his fellow wayfarers on that river of life. him very isolated and alone in rehab and nursing care facilities. Bob’s son, his wife and other family members were even- Since Iora encourages home visits, and since as his phy- tually allowed to visit with him, and I was honored to sit at their sician, I was allowed into these facilities, I became his regular side and hear his weekly stories. We became like family. Iora is visitor, and started home visits every 2-3 days. We regularly the first place I have ever worked where these kinds of sincere texted or called his son and wife to keep them in the loop. friendships with patients are encouraged. Although these visits were medical in nature, I felt the more My heart has found its home. important role was to be a “midwife” of sorts—helping Bob understand the coming “labor pains”, explaining certain transi- STEPHANIE tions in the dying process, encouraging the exploration of his life’s experiences and highlights, and then sharing these with Team Physician, | Tucson his family. 62
IORA CHAPTER EIGHT ASKS OVER THE PAST YEAR, I’ve had the pleasure of taking care of What’s your favorite a 71 year old man named Charlie. He has a complex histo- part of Huddle? ry including atrial fibrillation, morbid obesity, severe chronic pain, etc. Huddle is a very special part of Iora’s care model, Charlie was stuck. He had increasing pain which worsened and nearly 40% of Iorans told us that highlights/small his depression. He gained weight and became extremely de- conditioned. I would see him frequently in the office for heart victories/wins was their favorite part of this failure, acute pain and depression. He was so deconditioned morning meeting. that it would be a struggle just to walk from the reception to our exam room. At one point, he expressed suicidal ideation “Highlights will forever be one of my favorite and felt he would never improve. He told me he was a prisoner things that Iora gave to me. Hearing about in his own body. the patient interactions from the previous Over the course of 10 months, we were able to make day, and the personal wins, brought my meaningful changes. First, I got his heart failure under con- team closer. We shared losses and triumphs, trol and then I worked on his pain. We referred Charlie to our and that made us stronger and better at Behavioral Health Specialist group classes, and he became an caring for our patients as one team. I love active and thoughtful participant. the concept of highlights so much that I use My last interaction with Charlie was a phone call in Sep- it in my personal life with family and friends, tember. He told me he was doing wonderfully and had just especially when I know that someone needs come back from a half mile walk and never felt short of breath. help focusing on the small wins in daily life.” He had also lost over 50lbs. Most importantly, Charlie was able to lean over his table again to paint, his favorite hobby and something he was unable to do for months. Charlie no longer feels like a prisoner in his own body, but rather someone who has hope for the future. DANIELLE Team Physician | North Carolina 63
MEMORABLE PATIENTS The best doctors office I ever visited over the twenty plus years I lived in the United States. —GEORGIA PATIENT MY FIRST PATIENT INTERACTION at Iora was with someone who Iora team at work in Colorado seemed familiar, but I couldn’t quite place her face or name. After we completed her new patient visit, I left the room with the Health Coach for a moment. On my return to the exam room, she gave me a great big hug and said, “Dr. Shull, you were my mom’s doctor 15 years ago and helped her so much at the end of her life that I am so excited that you are now here to be my physician!” In geriatric Internal Medicine, we don’t always get the opportunities to care for families, but this continuity of care from mother to daughter, in a new venue, was such a heartwarming and honoring experience. HEATHER Team Physician | Colorado 64
CHAPTER EIGHT Patient enjoying a puzzle at Iora THE BEST DOCTORS OFFICE I ever visited over the twenty plus HAD MY FIRST APPOINTMENT with them. OMG everyone was years I lived in the United States. They were amazing, took time just wonderful. They take the time to get to know you and to examine me, thoroughly explained and went through every- your needs. They don’t tune you out when you tell them that thing. I recommend them to anyone looking for a primary care you prefer holistic ways. I feel confident in making this my new doctor. Thank you Iora Primary Care for promptly doing all my medical facility! referrals with authorizations. —NORTH CAROLINA PATIENT —GEORGIA PATIENT 65
09 Choosing Iora 66
“I can’t wait to see CHAPTER NINE where this journey takes all of us!” I ALWAYS KNEW I wanted to work in healthcare due to my own personal experiences. Because of this, I pursued a degree in IN 2016, I finished my Masters degree in Healthcare Delivery, my healthcare administration where I learned about the triple aim capstone project was almost rejected by the university because and value-based care. These concepts and ways of providing they did not believe that a delivery model straying away from fee care made perfect sense to me, and I was hopeful I could find for service could actually improve the health of patients in the somewhere to work that would care for patients with these long run - they called it impractical and unsubstantiated. When I concepts in mind, considering all aspects of a patient’s health! entered the workforce, I found that no one else believed it either. When looking for jobs before graduation I stumbled upon In mid-2019 I found Iora and immediately swooned! Final- Iora. I was so excited to see there were practices near my home ly, someone felt the way I felt, and didn’t treat people like dol- and that the Iora mission was to restore humanity to healthcare lar signs! I eagerly applied and was passed over. Fast forward 5 by providing care in the ways I was passionate about! My sec- months, I decided to stop hunting, and get certified in another ond thought was how helpful this could be to my grandparents interest of mine, phlebotomy. I was finishing my externship when who lived very close to our Shoreline clinic (where I hoped that I received an email from HR asking me if I was still interested in I would work!). Iora and when I could be interviewed. My initial interview felt like My grandparents are some of the most important peo- I was talking to a friend, then my in person interview was even ple to me. They were my daycare growing up - they watched better. I immediately felt like I was home, and getting the chance my sister, me and all of my cousins while our parents were at to use all of my skills with people who had the same ideals. The work. I’ve always known how lucky I am to have such a close stars finally aligned, and there’s nothing that can make me leave relationship with them and to be able to learn from them, so - I can’t wait to see where this journey takes all of us! picturing the type of care it seemed Iora would provide to patients just like my grandparents is what inspired me to do JENNIFER everything I could to work at Iora. It has been my motivation from the day I applied to be a Patient Enrollment Coordinator Operations Assistant/Phlebotomist | Phoenix in Seattle to now, here in Houston, helping to bring Iora to a whole new market. If you’re wondering, my grandparents moved a little further north and didn’t become patients (darn it!), but a different family member of mine did. I think about her all the time when I hear about what we’re doing for our patients, and it always makes me so proud to work here. AMELIA Market Operations Analyst | Texas 67
CHOOSING IORA “I am continually Emily and Jean excited to go to work each day.” I WAS THRILLED when I got the email that Iora wanted to inter- view me. A couple of days before the interview, I started writing I WAS FORTUNATE to work with many Iorans while I was at down questions I wanted to ask the interviewers. Whenever I Harken Health, and the impact of not only the people, but the had an interview, I always asked “what do you like most about mission stuck with me for years afterward. Being able to posi- working here?” I would typically get responses, like the flexible tively impact patient lives and patient care is a powerful mission. hours are great, the people are nice, or the bonuses and ben- Often in healthcare there are many factors and steps between efits are great. I would expect different answers depending on the work and the person benefiting from the care. Iora’s ability who I was interviewing with. to directly impact patients the way we do is why I was excited to At Iora, that was not the case. Each person I interviewed join and am continually excited to go to work each day. with had the same answer - the people. The people make Iora a great place to work. We motivate and inspire each other every- CHRIS day. The consistency in responses surprised me in a good way. I could tell the answers were genuine, and each person was Director, Product passionate about their job. As I was reflecting on the interviews, I knew I wanted to work at Iora and be surrounded by these 68 passionate and genuine people. Each one of us makes Iora a great place to work. We want each other to succeed, and we are passionate about transforming the healthcare industry to help patients live their best lives. CHRISTINA Senior Digital Marketing Analyst
CHAPTER NINE Renae, Alisa, Cornel, Mallory and Bryan I WAS A MOM-TO-BE when I applied to work at Iora, and work- IN HEALTHCARE, THERE IS a lot of talk about primary care trans- life balance was top of mind. In every company I had worked formation and team-based care. I have worked in systems that at prior, work was kept very separate from home life, and peo- believed in these things, but they had to try to fit the efforts ple didn’t talk much about their families. Being a woman in within the constraints of a fee for service healthcare system that tech can be isolating in some places, and some companies relied on transactions, billable codes and throughput. I’d talked to didn’t even have any parental leave policies at all. While we were able to make progress and change things When I reviewed the previous Iora Culture Book, I immediately around the margins, it remained a transactional system that noticed the presence of families and children in the employee moved at a snail’s pace and caused teams to work harder photos — and I knew right then that I would belong. while also compromising the joy of practice. Even before I officially accepted, the team was nothing but By joining Iora, I knew I was surrounding myself with supportive. I came back from leave as a new parent in a pan- people who wanted all of these things, but who were also demic, and the understanding and openness from everyone committed to showing that it can be done in a sustainable as we navigate these new waters together has continued to and fulfilling way. Although everyone has deep empathy for affirm my belief in Iora Health. We do great work at Iora. We patients and relationships, we are sustained by the common adapt, and we do it together. The company isn’t just a com- vision that we can get this right, and that the future of primary pany; we’re a community. We take care of our patients, team- care depends on us being some of the ones that figure out mates, and whole selves — family included. how to do it. LAURA LINDSAY Software Engineer | Minnenest Market Medical Director | Texas 69
CHOOSING IORA Sitting around the WORKING AT DIFFERENT HOSPITAL SYSTEMS, I was tired of the round table at a same exact thing. How to focus on timeliness and patient sat- typical patient visit isfaction scores at the cost of our own health and happiness. I once questioned myself if I was in the right career path. I’ll be “Now looking back, honest in saying that prior to joining Iora I had to do my re- my only wish is that search to understand who they were and the population that I would’ve found my they served. It was a very interesting find, as I never heard of new home sooner.” any facility that focused on just geriatrics. Joining Iora gave me a new and wonderful perspective on patient care and wellness. 70 I learned that there indeed existed a team based approach to patient care, where you didn’t feel alone or unsupported and where the patient had many resources and people to turn to and get advice. Now looking back, my only wish would be that the Iora practices would have been around for much longer and that I would’ve found my new home sooner. JESSICA Operations Assistant/Phlebotomist | Texas
IORA CHAPTER NINE ASKS SOME BACK STORY: I have two friends, Noelle and Chris, who What made you want to are long time Iorans. They often told me about how Iora was work in healthcare? transforming healthcare. They spoke of the culture, the peo- ple, the work and the mission. Everything they talked about was Why healthcare? Well, 50% of Iorans told us that positive. At the time, I was working for a company and was quite they entered into healthcare because they wanted comfortable. The hours were good, the pay was competitive and I enjoyed the patients I worked with. to help people. After two years of listening to Chris and Noelle talk about Iora, I finally decided to see what this place was all about. I was 13% said they didn’t look to work in healthcare, starting to notice that where I worked, there wasn’t a big sense but rather, Iora was their calling. of “team”, and it was starting to feel like the mission was only numbers-focused, even though it was a similar care model. “I knew I wanted to work in healthcare because The company was so big, I wasn’t even a small cog in a big gi- of my passion for helping others. I know how ant wheel. I felt like I needed a change, but I wasn’t sure. I first scary and intimidating it can be at a doctors did a sit-in at a practice to see how things worked. I was blown office and to not understand things the doctor away by the camaraderie I saw during Huddle and throughout is saying. I feel passionate about being able to the day. This was truly a team environment. I went through help patients understand and feel more confi- four interviews with each one being more informative about dent in their care. Iora and the company’s mission. By the end of the fourth interview, I was sure Iora was “2 main reasons: Medicine a special place. When I was offered a position, as scary as is fascinating and helping change can be, I was sure Iora was a place I could actual- people feeds my soul!” ly make a difference. Then…along comes a pandemic. After some very difficult months, I am now part of the float team “I wanted to find a career field where I and have the opportunity to participate all over the Phoenix could make an impact in someone’s life market. At every practice I have had the pleasure to work, I — no matter how small. At almost every have noticed common themes: the people who work here are level of healthcare, I feel there is the so very committed to the mission of transforming healthcare. potential to provide care, comfort and They are committed to our patients, and they are committed compassion that patients need.” to each other. 71 KELLY Team Nurse Practitioner | Phoenix
CHOOSING IORA I WAS LOOKING for a practice where I felt appreciated as a patient and not a Medicare burden. Iora filled the bill. They really are interested in getting to know you and supporting you in your journey to health and wellness. Facilities are beauti- ful and everyone on the staff is pleasant and friendly. —TEXAS PATIENT “...there is room to learn, Chris, Rushika, Boston Mayor Marty Walsh grow and be encouraged and Zander at the Nest to be YOUR best!” THE SMART, DRIVEN, compassionate, unique, and just all- “IT’S NICE TO GO into a doctors office where you are actually around incredible people (many of whom I now consider to be talked to, and treated as a person and not a number-and feel life-long friends) made joining Iora an easy decision. comfortable asking questions. I actually enjoy going to Iora Knowing that Iora is made up of motivated individuals who knowing that I will be treated with care. seek to do the right thing truly makes Iora a special place. It —PHOENIX PATIENT means there is room to learn, grow and be encouraged to be 72 YOUR best! Iorans are very relationship-oriented and want to get to know you professionally, but also personally! I’ve loved being able to share my family and so many of life’s special moments (like having my first daughter!) with my colleagues who are ex- cited to cheer me on throughout this journey. Life is short, and I look at my time being surrounded by such inspirational people (who are on a shared mission to restore humanity to healthcare) as such a gift, and I am so grateful to have found Iora! KATHRYN Director, Business Development
CHAPTER NINE Aurora wins the April 2019 traveling trophy for patient referrals WORKING AT MY LAST JOB, I felt defeated and not valued as Fast forwarding to the present, everyday I look forward to an employee. I wasn’t able to be my best self, and I was afraid going to work. I am very hardworking, and it doesn’t go unno- of what others would think about me being the one who was ticed. I am able to be creative and think outside the box. I love creative and hardworking. I decided to speak out against things that here at Iora I am able to put my foot in every job title and that were wrong. I dreaded coming to work everyday for two accomplish it. I am working harder everyday to be an example years. I wasn’t challenged, I wasn’t growing. I wasn’t motivated of all five of the Iora values: passion, empathy, courage, humility or appreciated. and creativity. I am experiencing personal development, and I One day I came across a Quote: “Be not afraid of growing am happy with my results. I have the pleasure of working along- slowly, be afraid only of standing still.” side a small but mighty team. I am learning new things everyday At that moment, I decided to take my life back by applying to about how I can be better and educate myself. work in a field in which I could spread love and creativity by work- I am thankful for taking courage to apply to a company that ing with patients. I started searching healthcare related companies, I see myself retiring and building with. and I found Iora. I found Rushika Fernandopulle on Youtube, and I watched how much passion he has for caring for older patients ALEXUS who are rushed and not listened to in the healthcare industry. Operations Assistant/Phlebotomist | North Carolina 73
CHOOSING IORA Iora runs in the 2019 J.P. Morgan Corporate Challenge helpful and appreciated. I am impressed with how Iora has handled the COVID-19 I STARTED WORKING AT IORA as a locum physician, plan- pandemic by conducting outreach to patients in the early stag- ning to stay for four months, and I am still here more than 18 es of the pandemic and immediately reconfigured skeleton months later! crews in order to protect team members and patients. I truly enjoy working at Iora as a Team Physician along I have had many encounters with patients sharing their sat- with our other care team members. I like Iora’s unique team isfaction with joining Iora as they recognized the special atten- approach to patient care, and I enjoy the camaraderie as well. tion we bring to their care. The way we care for our patients I believe that Iora has created the best outpatient geriatrics as a team on a daily basis is very much guided by the core val- model of care. As many of our patients present with complicat- ues learned during our first day of training: Empathy, Courage, ed past medical history, Iora offers a unique way to approach Passion, Creativity, Humility. geriatric care and make a difference in their lives. As a physician, having a trusted, well trained Health Coach to convey com- DARENIE plicated messages to our patients, having a Behavioral Health Specialist in house, having a nurse evaluate our patients instead Team Physician | Phoenix of sending them to the ER, as many offices do, is immensely 74
CHAPTER NINE “I feel fortunate to be a member of Iora Health and will take the values I have learned with me wherever I go in life.” I WAS MANAGING a complex cardiovascular specialty THREE YEARS AGO, I began my journey at Iora Health, program that specialized in new transcather procedures that enthused and determined to work for an organization that were recently FDA approved. was making such an impact on patients’ lives, not realizing Three years ago, an Iora Health Coach called to check the that my own life was going to be impacted as well. I joined status of a transcather mitral valve procedure for one of her Iora at a time when big transitions were occuring in my life, patients. At the time, it was very difficult to get a Humana and I often felt self-doubt in myself. Both my career and procedure authorization for these new procedures. The Iora personal confidence was shortly restored by my team, a Health Coach said they wanted to help and proactively asked group of authentic, smart, funny people who I have fostered for the CPT codes and information needed for the procedure some of the most meaningful relationships with to-date. authorization. That week, the Iora Health Coach called back Iora is a place where milestones are celebrated, life events, and let us know she got the procedure authorization. We were both happy and sad are recognized, where performance is able to quickly schedule the Iora patient to be treated. challenged and personal growth is encouraged. Iora has Those Health Coach phone calls really made me interested built so much positivity in my life, both inside and outside of in finding out what Iora was all about! The day when the Iora work, and has empowered me to be confident, work smart- Health Coach called back with the procedure authorization, er and follow my passions. As a member of the Talent & I looked up Iora and was astounded how there was an entire Culture team, I have had the pleasure to visit our practices and company with people just like her, with shared values and a have witnessed our team members create the same positive mission I really wanted to be a part of. There happened to be a environment for our patients. I feel fortunate to be a member Clinical Team Manager opening, and I clicked on the opportuni- of Iora Health and will take the values I have learned with me ty to be a part of the action in restoring humanity to healthcare. wherever I go in life. ROSE EMILY Clinical Team Manager | Washington Associate, Talent & Culture | Nest 75
CHOOSING IORA Playing cards with patients in Colorado “Thank you, Iora team. I JOINED IORA because I wanted three things: I know what it means, A healthy company culture where creativity was celebrated to hatch.” and team members were empowered to use their voice. A manager who trusted me and could give me the space PRIOR TO COMING TO IORA I avoided healthcare. I felt I to grow, who could create a safe environment for me to make needed to protect myself from a necessary evil. Now I feel mistakes and help me learn from the mistakes I made. in partnership over my healthcare and I am excited about my The opportunity to contribute to a meaningful company appointments. This started a new attitude on life for me. I’d mission where I could go home everyday knowing that I was recommend it to anyone. working to make the world better in the future than what it is —IORA PATIENT today. I got those three things and so much more than I could 76 have imagined the day that I joined the Iora team. MELISSA Senior Strategic Account Executive | Nest
Gerardo, Idan, Dave and Eric at the chili contest CHAPTER NINE Shannon and baby Jennie and Andrea I JUST COMPLETED my first week at Iora, and the only way I can express my profound excitement is through a poem! In a shell, trapped! I’ve been. Confined, constrained, hidden. Eager to rise, yet for a time, This body of flight, in incubation. How I’ve longed for the sky! In this cramped and crowded nest. To breach the clouds, my soul has cried! To flap through weightless winds! For to us, is meant a freedom. As vast as mountain horizon. Our frame was meant for soaring, To weave through rays of sun! Yet all begin, by waiting, In painful patience, growing. Hidden. Protected. Sleeping, in nest. Until that egg cracks. Thank you, Iora team. I know what it means, to hatch. CHRISTOPHER Team Physician | Washington 77
10 The Future is Bright 78
CHAPTER TEN “The potential is truly IORA’S INCREDIBLE POTENTIAL is endless, and that’s what tru- endless, and I can’t wait ly excites me. When I think about the company I joined over to see what we achieve six years ago, we are so very different (and yet the same in key together.” areas like culture and values). Back then, we weren’t in Medi- care, and we didn’t have market teams - we had multiple, locally AS I’VE HAD THE OPPORTUNITY to work at Iora for the past few branded practices (mostly one maybe two in a market) which years, I’ve observed a lot of progress overall, but I can specif- were delivering amazing care to a few thousand people. No one ically speak to our digital marketing work. When I joined, we had heard of Iora Primary Care because it wasn’t a brand yet! were just starting to leverage social media as a lead generation Since then and well before, Iorans have been working to- channel. We were looking for new channels to test and possibly ward a vision of transforming healthcare. To be honest, I didn’t scale. I was given the opportunity to test different creative ap- always think the path to transformation was 100% clear, but in proaches, different targeting methods and more. My manager looking back, I clearly see what progress we’ve made and how and team all respected the testing we were executing, because much we’ve accomplished together. We entered Medicare, we they knew it was the best way to learn and find breakthroughs have a unified consumer brand in Iora Primary Care across mul- that would take our digital marketing work to the next level. tiple markets, we serve thousands and thousands of older adults This same support and curiosity has kept me excited about in these markets and we even have patients who join us be- my role at Iora and will continue to keep me excited about cause their friend in another state told them about their amaz- working at Iora. I am excited for Iora’s future because leadership ing Iora care team. People know us, and they look for us. The and Iora’s culture have created a space where brainstorming, change from 6+ years ago is downright amazing. Just imag- testing and asking the tough questions is safe and encouraged. ine what we’ll be in another 10 years! We’ll continue to grow, which means positively impacting so many more people (and GENEVIEVE their families), influencing so many other healthcare players to practice care like we do, driving true community with our pa- Senior Manager, Digital Marketing | Nest tients and others around our practices...and so much more. The potential is truly endless, and I can’t wait to see what we achieve together. KATHLEEN Vice President, Communications & Patient Experience | Nest 79
THE FUTURE IS BRIGHT AMAZING CONCEPT FOR PRIMARY CARE for senior citizens 65+ or on Medicare. No rushed appointments. They really listen. “Great things are They return calls & call you with test results whether normal or ahead for Iora!” not! They provide transportation to your appointments if you need it! Gasp... I am not lying... They are amazing. —WASHINGTON PATIENT Karina, Marquita, Maddi, Michael, Greg and Brianna The Broadway team BEING OUT IN THE COMMUNITY and having people know about WHAT EXCITES ME MOST about Iora’s future is the growth of Iora is exciting! Six years ago, tabling at events was difficult, as the company. Thanks to the great work by a lot of great people, no one knew about Iora and our excellent patient care. Going we have a unique opportunity to expand our reach by touch- from “Who are guys?” to “You are my provider” is rewarding. It’s ing and impacting even more lives. The best way to transform amazing to see the impact Iora has made in our communities healthcare is to reach as many people as possible and make an and will continue to have in the future. impact. Great things are ahead for Iora! LIZ DURIEL Senior Analyst, Growth Operations | Nest Market Operations Leader | Georgia 80
CHAPTER TEN WHEN I JOINED IORA seven years ago, I had no idea that it Georgia Grand Opening 2019 would become such a source of personal and profession- al growth for me. When I showed up at the old Nest on Third derful to our organization, deepening the culture and making it Street in Cambridge, I was excited to work for a company that richer. Each time we add a new perspective, location or patient spent time with patients, that incorporated public health princi- population, I don’t feel like we are losing the good things of ples into every decision made and that was embarking on a bold the past, but rather gaining new insights and broadening the and audacious goal. Iora community. In this remote era, I am so proud of how we What I didn’t know then was that I would have the privi- have adapted together, keeping our care for each other and our lege of working alongside a group of people from every corner curiosity to keep learning at the center of what we do. I have of the organization that would inspire me to keep learning and felt so very lucky to work here since my very first day, and the growing in service of our mission. When I think about what ex- evolution of the organization makes me feel even more grateful cites me most about the future of Iora, it is the way that each for the adventures ahead. new person that I meet at Iora adds something new and won- JENNIE Senior Director, Talent & Culture | Nest 81
THE FUTURE IS BRIGHT Alameda Crossing Grand Opening 2019 I HAVE NEVER HAD a more positive healthcare experience than IN EVEN JUST THE THREE YEARS I’ve been at Iora, it’s been I have since I teamed up with Iora. The time taken at each visit incredible to see how much the industry has evolved to is phenomenal. Every staff member has the greatest personality begin to recognize the need for and value in the care Iora pro- and I have a sense that the whole team really cares about me. vides. Adapting, with the rest of the world, to the changing This is not a healthcare “factory” which is the case with most environment of COVID19 highlights the importance of per- private practices today. I feel so blessed that I got connected sonal relationships, listening, and being compassionate (being with Iora and Humana. I spent 30 years working in healthcare. HUMAN!) to others, now more than ever. We have such incredible Never seen anything better. momentum in the industry and I am excited for how Iora will —TUCSON PATIENT continue to innovate to create incredible and meaningful expe- riences for our patients and communities. 82 KATHRYN Director, Business Development | Nest
IORA CHAPTER TEN ASKS WHAT EXCITES ME THE MOST about Iora’s future is that we are What’s one word GROWING. Iora’s growth means that there are more patients to describe Iora? getting the care that they need and deserve, thus further ac- complishing our mission to restore humanity to healthcare. I am It’s hard to use just one word to describe Iora — our so grateful to be a part of this company and to witness all the employees did just that but wow were there a lot of obstacles that we have overcome. Looking forward to seeing what the future holds for us! different words submitted! SHA mission-driven Analyst, Growth Operations | Nest groundbreaker energetic I AM VERY EXCITED about seeing the name recognition Iora has family astonishing community had in our medical community. This makes me proud! supportive Part of my role as an RN is to stay in close touch with patients and their family during and after a hospital stay. I also evolutionary home hope bold communicate with hospital staff during a patient’s hospitaliza- tion. When I first started working at Iora, almost five years ago, ine cient persistent incredible hospital staff would be hesitant to speak with me. They would often ask, “who/what is Iora?” Now when I call, the staff never amazing ask those questions. easy We have become well known and respected in the medi- innovativeextraordinary welcoming cal community for the genuine care and attention we give our patients, and this makes the future even more exciting. passionate masterpiece life-changing MAUREEN visionary caring adaptive daring Team Nurse | Washington forward-thinking inspiring determined team-based compassionate transformative revolutionary camraderie 83
THE FUTURE IS BRIGHT WE ARE CHANGING the face of healthcare. I’ve seen it over the last three years working here, and it’s a beautiful thing to watch “The most exciting and be a part of. Our leadership is transparent, passionate, sup- thing about Iora’s portive and humble, and I have full confidence in their decisions future is that Iora IS as they drive our Iora train toward our goals. the future.” COLLEEN EVERYWHERE I LOOK, health policy, medical ethics, public opin- ion and medical worker wellness news describes “the future of Team Nurse Practitioner | Tucson medicine” as an imaginary world where patients and healthcare teams work together to do the right thing for the right reasons. INSTEAD OF FOCUSING on the founders of the ways that be, I can’t help but smirk, because Iora built that world, and we’re focus on being the founder of the ways that should be.” This already living in it. The most exciting thing about Iora’s future is quote resonates with me and why I joined Iora. It’s also what I that Iora IS the future. am most excited about with Iora’s future. I have watched this company continue to focus through the SARAH most challenging times in our country. Despite every obstacle and setback we have faced, our mission and what we believe Care Team Medical Director | Texas continues to drive us forward. I see Iora building a new normal in the healthcare industry. It’s what drives me to give 110% ev- 84 ery day. This is the first company that I have worked for where, when I picture 5 years from now, I am not envisioning my role or what promotions or accomplishments I have achieved. I pic- ture the company being the standard in the healthcare industry. I see myself being a part of something greater than myself. This is what drives and speaks to the culture at Iora. DARRYL Director of Patient Growth | Nest
CHAPTER TEN Julie, Eliot, Ellie, Rusty and Will 85
CELEBRATING 10 YEARS OF IMPACT Our Reach WASHINGTON (6 Practices) MINNESOTA NEW HAMPSHIRE BOSTON, MA (MinneNest) (1 Practice) (The Nest) COLORADO HYANNIS, MA (6 Practices) (1 Practice) PHOENIX, AZ NORTH CAROLINA (12 Practices) (5 Practices) TUCSON, AZ GEORGIA (3 Practices) (7 Practices) TEXAS (6 Practices) 86
Boston, MA (The Nest) North Carolina Colorado Texas We are currently in our third We opened the North Carolina We opened the Colorado market We opened the Texas market in Nest since 2010, with each move market in 2019 with 5 practices. in 2015 as the third market 2019 with 6 practices. This was matching the growth of our team. focused on Medicare. the largest market entry for Iora. This was Iora’s first market to The market launched with 5 Home of the original “Bell” that open as multi-payer. Home to Iora’s newest practice Iorans who had previously we ring to mark successes (and South Federal—which opened in worked in other markets. the origin of “Ring The Bell” First time opening a market October 2020! Iora physicians and Behavioral headlines to announce wins). with two submarkets launching Health Specialists have simultaneously. Iora’s third largest market with faculty appointments with the Hyannis, MA 6 practices across the Denver University of Houston College of Georgia metro area. Medicine, which opened in 2020 We opened the Hyannis market with a focus on primary care and in 2019. It is the fastest growing We opened the Georgia market Phoenix, AZ the underserved. Medicare practice in Iora’s with 3 Medicare practices in Medicare history, serving Original 2018, and it has since grown to 7 We opened the Phoenix market Washington Medicare and most Medicare practices. (with Seattle) in the first year we Advantage payers on Cape Cod. started serving Medicare patients. Our Washington market is home Iora had a previous presence The Phoenix market launched of Iora’s first Medicare practices. One of our dear patients in Georgia which makes it the Indian School and Peoria We opened the Shoreline and diligently hand-carved an Iora the home of the most Ioran practices in 2014. Central District practices in our bird which now lives in our “Boomerangs”. first year of serving Medicare reception area! (see page 60) Iora’s largest and fastest growing patients (along with Phoenix). The team affectionately calls market with 12 practices and This market has some of the New Hampshire themselves “Team Marvel”. over 13,000 patients. most diverse neighborhoods — our patients speak Spanish, Home of Iora’s first practice— Minnesota (MinneNest) Fun Fact: Iora started its Mandarin, Vietnamese, Dartmouth Health Connect— operations in Arizona out of an Cambodian, Tagalog, Russian, which serves a number of We opened the MinneNest in apartment in Phoenix equipped Ukrainian, Somali, Arabic, payers. The largest is Dartmouth June 2015 when John Norman, with phones and more! Swahili and Japanese just to College employees and their who had been working remotely name a few! family members. We also serve almost since Iora was founded, Tucson, AZ The Washington market has 8 King Arthur Flour employees and realized that we could hire some different team members who as of 2017, seniors on Medicare. extremely talented engineers We opened the Tucson market have been with Iora for 5+ years. outside of Boston. in 2015 with the Broadway and Unique from our other locations, Grant practices. 87 this practice offers care for Besides engineering, product patients ages 18 and up. management and design, the This market opened a third MinneNest is also a home base location at Pusch View in 2018 for our COO, Suzanne Hansen. with an incredible grand opening. Besides Minnesota and Boston, Fun Fact: The only market that we have engineers in VA, FL, you don’t have to drive on a and PA. freeway to get to all the practices (which can be good and bad).
CELEBRATING 10 YEARS OF IMPACT IORA IO YEARS ON DEC 20, 2010, Chris McKown and I filed the charter to cre- on thousands of peoples’ lives. ate a new company called Iora Health. Looking back, we’ve The German philosopher Arthur Schopenhauer once come a long way since then. At that time, we had no practices wrote, “All truth passes through three stages. First, it is ridiculed. or patients, we didn’t have our own IT system to guide care, we Second, it is violently opposed. Third, it is accepted as being didn’t have this phenomenal team, nor had we articulated our self-evident.” When we started Iora people thought we were values, improved our care model, signed any contracts...the list crazy. Then, at various times during the last decade, we’ve been goes on. What we did have was a bold vision and a dream we fought by the medical-industrial complex which, despite its knew we could achieve—to transform healthcare—to radically rhetoric, benefits from keeping people sick and dependent on improve how people are cared for and to improve their lives and them. But now, even the traditional healthcare institutions are their health. realizing that what we started 10 years ago is the right direction And together with every Ioran, we have done just that, for for the industry. tens of thousands of patients, and hundreds of colleagues, in Many traditional health systems now talk about human cen- dozens of practices all over the country. tered care, more and more payers are encouraging value-based Iora Health is an underdog in this role of transforming a very contracts, more Iora-like competitors are springing up in various large, very old healthcare system. This is not easy to do, yet de- flavors, and more digital health companies are going beyond spite being an underdog (or perhaps precisely because of this), the traditional Electronic Health Record to engage consumers we are making an incredible mark on the industry and of course in their health. Indeed largely as a result of our example and advocacy, the Centers for Medicare and Medicaid Innovation 88
CLOSING designed and is implementing a new Direct Contracting Model And we will keep inspiring (and challenging) the rest of the to allow us and others to spread our consumer-centric, digital, industry to join us in truly restoring humanity to healthcare. value-based model to millions of seniors across the country. We have a lot of hard work ahead of us, but the winds are Looking forward to Iora’s second decade, we will continue now firmly at our back. I could not be more excited about what to improve and adapt our clinical model, technology platform we have accomplished over the last ten years and where we and service delivery. While what we are doing is already far bet- will go in the next ten. I am honored to work with all of you and ter than the status quo, we know there are many ways to make to celebrate our contributions and achievements in this year’s it better for our patients, our teams, and our outcomes. Culture Book: Celebrating 10 Years of Impact. Here is to the We will continue to aggressively grow to serve more pa- next decade of Iora Health. tients both within the markets we are currently in, as well as expand to new markets. This could include entering into new RUSHIKA countries that face the same challenges of rising chronic dis- FERNANDOPULLE ease and aging populations that we address. We will continue to form new partnerships with like-minded MD, MPP organizations to expand Iora and fulfill our mission. We will keep a laser focus on our values and culture to CEO & Co-Founder ensure that we are working at a company we can all be proud December 2020 to call our own. 89
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This book is dedicated to all Iorans and the patients we serve: thanks to you we are able to celebrate Iora’s 10 years of impact.
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