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Enteral Therapy as a treatment for Crohn's disease


[Editor's note: This article was originally published in CIRCLE May-June 2013]


Enteral therapy refers to providing nutrition as a formula rather than by eating a regular diet. Enteral therapy has been shown to be effective in inducing, and perhaps maintaining, remission for pediatric patients with Crohn's disease. Enteral therapy does not have the side effects seen with drug treatment, and can improve growth, unlike corticosteroids, which have many known side effects. Although used very little in the United States, enteral therapy is commonly used abroad, including many European countries and Japan.


Over the years, several methods of administering enteral therapy have been evaluated, leading to variation in treatment. In 2012, the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) formed the Enteral Nutrition Working Group to review the use of enteral nutrition therapy in pediatric Crohn's disease, which summarized previous research and offered recommendations for physicians.


Drinking FormulaHistorically, enteral therapy was given through a feeding tube, and this is still done at many centers. However, drinking the formula is also an effective option. Studies have used both specialized nutrition formulas (in which the protein has been broken down to into smaller pieces) and non-prescription over-the-counter formulas (in which protein is not broken down). Both approaches appear to be equally effective, an important finding since over-the-counter formulas taste better and are less expensive.


The majority of the research has shown that enteral therapy is effective when taken as the sole source of nutrition (that means the patient can't eat any food), and this approach was recommended by the NASPGHAN Enteral Nutrition Working Group. However, recently a study published by Children's Hospital of Philadelphia showed that enteral therapy protocol is still effective when a small amount of food (less than 20% of the calories) is taken at the same time.


The way enteral therapy works is unclear. Theories include that it may help to provide the body with important nutrients and better overall nutrition, eliminate an unknown dietary substance that causes an immune response, or alter the bacteria found in the intestines.


A perceived barrier to enteral therapy is that the treatment may be demanding for physicians, families, and patients. For example it may be difficult to start, expensive, create a need for a feeding tube, or be displeasing to patients. Nationwide Children's Hospital is developing and testing a simple enteral therapy protocol which could be started very quickly and could be used at other GI centers. They plan to work with families and patients to reduce the perceived barriers via education on cost issues and payment options, and by developing a mentoring program. If successful, the protocol could significantly decrease the number of newly diagnosed patients with Crohn's disease who are initially treated with corticosteroids. Stay tuned.


Jen Smith, MS, RD, LD, LMT, Clinical Dietitian
Nationwide Children's Hospital, Columbus, Ohio




Sometimes you don’t know what you’ve got till it’s gone…


The announcement from Daniel McLinden that the ICN Exchange was back up.

 

Recently, the ICN Exchange needed to undergo maintenance unexpectedly for two days. Some people in the ImproveCareNow Network probably noticed it more than others. I know that as someone who has come to rely on it to keep up with what centers are working on and looking at, I was keenly aware of its absence.  So you can imagine how thrilling it was when it came back online!

 

Now that the Exchange is back up and running (and better than ever - with plans and resources in place to prevent such outages in the future!) it occurs to me that even a quick glance at the Exchange clearly shows the richness, diversity, vibrancy—and the multifaceted dynamics of our community.

 

When I glanced at the Exchange today this is what I saw:

 

Children's Hospital of The King's Daughters' DIGMA model demo video from the Spring 2014 Learning SessionImproveCareNow centers, like Children's Hospital of The King's Daughters, jumping in and collaborating with parents, patients, and other centers to make sure that we are all learning together!
Call for clinicians to sign up for a focus group to dicuss what has worked and what hasn't worked when trying to get patients and families involved in QI work at ImproveCareNow centers.

 

Opportunities that highlight how much we really, really want and need to learn from each other so we can collaborate even better!

 

The first ever announcement for a ImproveCareNow Dietician webinar Multidisciplinary partners, like the RD group, are staying connected with each other and getting organized so they can The new online 90 day goals tracker for ImproveCareNow centers to track and monitor their Improvement project goals and progress quarterlytake on projects that will build their visibility and leadership in ImproveCareNow.

 

ImproveCareNow QI teams are becoming even more accountable and transparent in their day-to-day QI work.

 

The Parent Working Group of ImproveCareNow is now setting and working on 90 Day Goals and in the spirit of transparency is sharing them with the whole NetworkParent Partners are setting their 90 day goals, tracking their progress and keeping the Network informed!The Patient Advisory Council request to ImproveCareNow participants to co-produce an Ostomy Toolkit for patients with permenant or temporary ostomies.

 

And finally, amazing patients around the country are teaching us more and more every day.


 

And that is just a quick glance! So thank you to everyone who has been a part of helping us build this vibrant community. I, for one, can’t wait to see where the community goes next!



The ICN Exchange is an internal knowledge-sharing platform that the ImproveCareNow Network uses to communicate, collaborate and innovate across the miles. Clinicians, Researchers, Patients, Families and Improvers are able to log into the ICN Exchange and share seamlessly and steal shamelessly!  The ICN Exchange has enabled ImproveCareNow to extend our “all teach, all learn” collaborative approach to medicine far beyond our monthly webinars and twice-annual Learning Session. It allows us to identify ideas and best practices in pediatric IBD care and introduce them into the care delivery process much faster—improving care for our patients now.


Back to [basics] school

https://twitter.com/Sarituno/status/448862983939436544

I have been working with ImproveCareNow - a Network that uses Quality Improvement (QI) techniques to bring about improvements in the care and health of children and adolescents with Crohn's disease and ulcerative colitis -  for nearly 3.5 years. And, yet I have not had any formal QI training. That ends now, because I'm taking the Spring 2014 QI Fundamentals series.

QI Fundamentals is a series of seven, hour-long webinars lead by one of the Network's QI coaches and a project called an Applied Learning Opportunity (ALO). The curriculum has been designed for teams who have just joined the ImproveCareNow Network and new members of established teams. By the end of our six months together, a QI  Fundamentals class graduates with knowledge and understanding of basic QI skills and tools that ImproveCareNow uses to drive measurable improvements.

New teams are encouraged to focus their ALO on registration and data collection, which means many will choose a project that helps them identify IBD patients in a much broader patient population. This basic ability is so foundational to the QI work that each team will be doing in the future. Remission rate for IBD patients at each center, for instance, is calculated based on the total population of IBD patients - so dialing in a process for knowing all patients with IBD is critical so a team can accurately see how they are doing in terms of getting more patients into remission and keeping them there.

You're probably thinking to yourself, the number of patients with IBD (which we call a "denominator") must change over time as new patients are diagnosed and as others transition out of pediatric care. And you'd be right. But don't worry, the ICN data management team has got that covered. They request quarterly updates from all participating ImproveCareNow centers. So, I'd say it's pretty fundamental to know how to identify patients with IBD at your care center.

This begs another question. Since I'm not part of a team at a care center (read: I don't see patients), what will my ALO be? Well, I'm glad you asked. The answer is: you're looking at it. Yup, I'm focusing my ALO on LOOP. In fact, here is my aim:

Applied Learning Opportunity AIM for Sarah NocitoSo, I'm walking the walk - reading up on QI, planning and carrying out my own ALO, complete with aims and run charts and data oh my, and probably even presenting my results at the Fall 2014 ImproveCareNow Learning Session (which is September 4-6, if you're wondering).

Look for my next post after the second Fundamentals webinar on April 9th.


When working for becomes working with...

Look on Twitter, Facebook, LinkedIn, and many other social media outlets over the past few weeks, and ImproveCareNow is all over the place. Many quotes about “parents as partners,” “real patient engagement,” and “amazing collaboration.” It’s fantastic to see the buzz we are generating. It’s huge, and important, and feels like it will catalyze many others who are working on similar efforts to jump in and do the same. We have a lot to teach now, even as we learn. It’s helping us achieve health outcomes we did not think possible and will probably help others do the same.

 

But what does this mean at the micro level, in the day-to-day shuffle (and sometimes tornado!) of getting the real work of running this complicated Network done? I don’t pretend not to realize that the care teams out there across in our 65 centers are doing the hard work – planning visits in advance, getting to know our new automated reporting tools, and trying to fit this all into their already complex clinic workflows. They (with the families they serve) are real heroes in this Network. But a lot of work also goes on at the ImproveCareNow leadership and staff levels to make it all possible. And I consider myself very fortunate to be in the position, as part of this team, where I get to see how many of the pieces fit together, and witness the not so subtle shift in what it means to “work for ImproveCareNow.”

 

I’m going to use our recently completed Spring Learning Session as an example. Even just one year ago, planning the Learning Session meant that the core Quality Improvement (QI) project team and I looked at Network priorities and recent lessons learned, identified who would do a good job speaking about these things, and pieced together what usually turned out to be a good agenda for a good meeting. Parents and patients were starting to attend Learning Sessions, but were on the fringes and some would tell you they spent their weekend trying to figure out where they fit in. We felt good about including them, but we didn’t feel good about not understanding quite how we all fit together.

 

What a difference a year can make! In planning for the Spring 2014 Learning Session I found myself watching as unprecedented collaborations between clinicians and parents, data managers and parents, took place across the miles. In one instance, what began as an offhand comment about the potential for a parent panel at the Learning Session, which would address how centers can better engage families in QI work, became a series of many, many emails between a clinician, several parents, and ImproveCareNow staff. Over three months we worked together to co-design the objectives and draft a call-to-action that the panel could deliver to the Network. The result was one of the highlights of this Learning Session.

 

In another instance, a parent asked for permission to use Network remission data in his presentation—the kind of data that he knew could illustrate the ImproveCareNow story best. Again, I found myself watching an amazing email discussion unfold between the parent, our ImproveCareNow data manager and the centers that agreed to have their data displayed in a novel way by a parent. This kind of conversation about data (“send me that,” “no, let’s try it this way,” “yes, that will have the most impact”) happens all the time within ImproveCareNow. But until now, had been limited to QI, data management, communications, and IT staff.

 

I used to believe ImproveCareNow staff and leadership needed to work for the clinicians, parents, patients and others that make up this Network…they were partners, but also customers and we had to make it all work well for them. I now realize it’s all about working with them so they can help us get things right. So yes, I work with the many care teams who are providing more proactive and reliable medical, nursing, nutritional, social work, and psychological support to pediatric patients with IBD. But I also work with Justin, Jamie, Sami, JenJo, Jennie, Tania, Beth, David, and many, many others who have ideas and experiences that also need to be integrated into this learning health system.

 

Today these patient and parent partners email me just as any of my other coworkers would. They email me during the work day, but also at 11:00 PM and 4:00 AM, during their time. They do so despite having busy full-time jobs inside or outside of their homes and despite the extra time they already devote to caring for children with a chronic illness. They share their ideas, ask for my input, worry about pushing us too fast (I often hear: “we’re not going to get you all fired, are we?”), worry about not pushing us fast enough, and ask how my kids are doing. I push them to post things on our internal knowledge-sharing platform, the ICN Exchange, just like I push the care centers. They are creating 90-day goals to focus and guide their work just like the care centers.  Most of all, they are helping us walk together into a new model for running this Network, understanding we won’t get it right every time, caring about the impact on others who are new to this level of partnership too, and above all, making sure we all stay connected to what this work is really about:

 

 

 


Parents as partners in care

One of the joys of working with the ImproveCareNow Network is seeing the results of co-production introduced more broadly to a learning community. At the same time, communicating what this is all about can be tricky – the idea that patients and clinicians can actually be partners (in health, care, improvement, and research) - is such a paradigm shift.  In fomenting this culture change, we have come to a deep appreciation of story-telling, art, and other creative expression as a powerful way of communicating beyond the hard data. That's why it's so breathtaking when we see this come along:


https://twitter.com/michaelseid11/status/448458248627027969

Justin, who made this video, is a parent in the ImproveCareNow network.  Collaborating with other parents and with some (minor) input from ImproveCareNow staff, he distills, in less than 90 seconds, this movement to its essence so much better than my feeble words could do.


Drum Roll Please...

In only a couple of days, there will be a flurry of texting between Sami and I, sending pictures of packing and potential Learning Session outfits back and forth. Yesterday I sent Sami a few pictures of a sample outfit, to which she instantly texted back, “I like it!! It looks professional and cute!” (Note: said outfit was, indeed, packed immediately)

 

Last night I was pouring over an email with the Learning Session agenda, clicking on the various hyperlinks for teasers about the plethora of exciting things to come. One link sent me to pictures posted on the ICN Exchange of various ImproveCareNow teams; I chuckled at the Boston Children’s Hospital team’s faces photo-shopped onto duck statues (a la Make Way for Ducklings), the Children’s Healthcare of Atlanta team’s matching t-shirts, the MassGeneral Hospital for Children team’s “We love ICN” sign (complete with a full GI tract doodle), and – finally – the ICN Exchange “Team Oscar Selfie” (a gutsier version of Ellen’s now infamous Oscar celebrity selfie).

 

Nothing like previewing pictures of the big-hearted, gutsy-humored, determined-with-all-their-might-to-change-chronic-illness-care care center teams to get me excited about the Spring Learning Session!

 

Spring 2014 ImproveCareNow Learning Session

 

Sami and I have tried (and, notably, failed) at accurately articulating the pure excitement, joy, motivation, and positive energy that’s simply contagious at the Learning Session. Here in text, it sounds cheesy and like ImproveCareNow is prodding us to write down such ooey-gooey sentiments. But, let me reassure you on behalf of Sami and myself, our ooey-gooey praise is exceedingly well-deserved and comes directly from our hearts (read: guts).

 

In addition to the undeniable culture of optimism and innovative thinking, there are always particular sessions we just cannot wait for. Following are the things we look forward to most at the Spring Learning Session:





    • PAC Reunion: The Learning Session is the one time when the PAC Leadership is able to brainstorm in-person (and also eat lots, and lots of candy!). We look forward to seeing each other face to face, and are always astonished by the amount of important work we get done in a couple of days. This Learning Session will be the first where our full PAC Leadership will be in attendance (PAC co-chairs - Jennie & Sami, and Patient Scholars - Katherine & Tyler) – we just can’t wait!!

 


    • QI Fundamentals: Sami and I stumbled upon this last year as we both arrived early, and were quickly enthralled with the phenomenal centers who are our newest family members in the network. This is a wonderful opportunity if you’re in need of some inspiration (note: by the end of the weekend, you’ll be bursting with inspiration!) or a Quality Improvement refresher, and is a fantastic way to meet upcoming superstars in the network.

 


    • Opening Reception: Here, there, and everywhere – the reception is filled with amazing people and is an awesome chance to network, socialize, and get the 411 on the network’s progress and innovations with the variety of poster presentations. Also, keep an eye out for some Patient Advisory Council members who will be reprising their roles interviewing reception attendees!

 


    • The Learning Health System Today and Tomorrow: The opening never fails to deliver in motivating every cell of every attendee, and – who are we kidding – we always love seeing Dr. Margolis and Dr. Colletti (and, if we’re lucky, they’ll coordinate their outfits!).

 


    • Lunch: Food, food, more food, and lots of networking! We always fill up with some nourishment and get the chance to meet new centers, parents, and the clinicians at various centers that we are humbled to call friends.

 


    • The Learning Health System, The Months Ahead: The closing is reliably the time when you will need a stash of tissues compliments of the remarkable speeches from parents and patients. After the excitement of the weekend and the endless research ideas and connections you’ve developed, the closing is a perfect opportunity to digest (yes, pun intended) the entire experience and head home with genuine motivation that you won’t soon forget.



We can’t wait for the collaboration, the innovation, the passion, the insight, and to continue to watch children and their families living with IBD receive better, and better holistic healthcare.

 

So pack your bags (or join us on Twitter and follow the Learning Session hashtag #ICNLS) and get excited – the Spring Learning Session is just around the corner!

 

Jennie + Sami


Sitting In It

Or "The Crystal Ball Method of Informed Consent"

Why didn’t I know how hard this was going to be?  When is it going to get better? Will it? Is it even worth continuing?’  I don’t know how much longer I can keep going, especially when I hear there isn’t an answer to this yet; my pain isn’t going away!’  As a child I felt that myself sometimes, and I think my patients feel that way sometimes, too.

 

Read more

Transitioning at Children's Mercy Hospital

When I was little, I had a lilac-purple colored bicycle. There were shiny streamers at the ends of the white handlebars, which would often catch the wind as I rode through a field near our house, my parents cheering and running behind me holding tight to the lip of the seat. Having gotten used to the stable comfort of riding my tricycle around our quiet suburban cul-de-sac, I remember feeling both terrified and thrilled at the expanse of the field and my ‘big girl’ two-wheeler. Learning to ride my bike – like most things in life – was a skill that required a lot of technical and emotional support from others, and a belief that I could do it.

 

A few months before I graduated high school at 17, I went to the hospital with my Mom for the so-called “transition appointment.” We had been sheltered and insulated in the pediatric world, full of pastel-colored murals, teddy bears, and bandages that were cut into heart shapes. The adult medical world was cryptic and distant – a new building, new doctors, new nurses, new everything. While everyone was perfectly polite, the transition appointment consisted of being told which adult doctor I was going to see and when/where I had to show up; there were no choices, no decisions, no questions. And there was no road-map for how to get from point A (pediatric care) to point B (adult care).

 

There are two important concepts that often get conflated: transition is the careful, premeditated, and inclusive process of educating and empowering an individual to be responsible for one’s health, while transfer is the physical change of moving to a new medical facility (e.g., pediatric to adult hospital). Transition is the meaningful process of gaining and growing skills like medical literacy, advocacy, adherence strategies, and so on. It requires a team of people (patient, parent, pediatric and adult doctors, nurses, etc.) working together to empower the patient. It’s the difference between learning to ride that little purple bike in a big field with lots of support versus just being given the bike with no guidance about how to use it.

 

According to Dr. Michele Maddux, a clinical psychologist at Children’s Mercy Hospital, who helped develop their transition program, Mercy’s efforts had previously involved transferring medical records and, “finding an adult provider, with significantly less focus on equipping adolescent patients with the tools and skills needed to successfully manage their health care needs.” Seeing this gap, Dr. Maddux and a dedicated transition task-force set out to create a holistic transition program that managed the clinical issues while taking lifestyle matters and family perspectives into account. They started by interviewing each of the pediatric gastroenterologists (GIs) on service to ensure physician engagement in the project and to capture their unique perspectives. They also created a GI roundtable and invited pediatric and adult GIs to have transparent conversations about transition. This resulted in a provider database and helped to dispel some of the myths that pediatric and adult GIs had about each other. The success of the roundtable and the transition task-force’s efforts culminated in the hiring of a transition coordinator and the development of a transition readiness screener for patients as well as educational materials for patients and families undergoing transition. The educational materials were vetted by Mercy’s general parent and teen advisory boards (i.e., not IBD specific) and by parents of children living with IBD.

 

Cue Jamie Hicks – a perfect fit into the role given her nursing background and a busy mom of three, including 10-year-old Colson who lives with Crohn’s. Prior to reviewing the transition materials, Jamie said, “[i]t simply wasn’t on my radar… I think of him growing up and how the disease will impact his future. But I never linked that to him taking over my ‘job’ as the manager of his health care.” Jamie praised the educational materials as “fantastic”, underscoring the importance of a defined direction and plan over guessing and uncertainty. Jamie’s main contributions were adjusting the material’s language, which she believes can have a large impact on how the information is received and understood by kids and families. According to Dr. Maddux, “Jamie brought a much needed patient/family voice to our materials that gave us a unique opportunity to craft our educational materials to meet the needs of families.”

 

Both Dr. Maddux and Jamie reiterate the vital importance of creating space for parents in research projects. Dr. Maddux pointed to the language and format changes as key edits that would have gone unaddressed without parent and patient engagement. Jamie addressed the critical role parents play as the people who most intimately understand their children beyond the clinic by helping to appropriately tailor educational materials and provide ‘behind the scenes’ information about children's motivations and worries. Similarly, they are both passionate about transition being relationship-based and starting as early as possible so the changes in medical responsibility are empowering and fitting for each child and familial situation.

 

We may not have a cure for IBD, but thanks to the insight and persistence of Dr. Maddux’s team and parents like Jamie, it is possible to implement a comprehensive, team-based transition program that prepares young patients with IBD to manage their own care. We can give our patients the encouragement, support, and information they need to ‘ride their bikes’ with strength and confidence.

 

After dozens of tries back in that field on my purple bicycle, I finally pushed off the ground, my feet finding the pedals and my eyes trained on the horizon, newly sturdy and sure of myself, and off I went pedaling across the field as my parents clapped and whistled. It hadn’t been easy, but I did it.

 

And together, we can make sure all of our kids can do it too.

 


Together

I met with up an old friend for tea. As we were standing in line, she asked about my college friends and how they were doing. I started talking about one, and she interrupted, asking, "Is that the girl with Crohn's?" "No," I said, and named another disease. My friend smirked, and said, "Do you have any healthy friends?"

It's an ongoing joke amongst my family and closest friends that, in order for me to know someone, they have to have a chronic illness. To an outsider examining those I have chosen to be 'my people,' it would indeed seem that having an illness is some form of a requirement - the vast majority of my close friends have chronic illnesses. The natural thought is that we're friends because of being young with chronic illnesses, but that is not completely true.

They did not choose me because of my illness, or in spite of my illness, but rather they chose me with my illness. Living with a pediatric chronic illness has been, in my experience, a simultaneous growing up and growing down: the growing up is bumpy and circuitous, while the growing down is shirking off the medical maturity and fumbling to fit in and understand peers without disease. I have several wonderful, empathetic, incredible friends who - surprise, surprise - do not have chronic illnesses, and these people have been unimaginably understanding, supportive, and encouraging. But, in light of a variety of challenges my friends with chronic illnesses have been facing, I wanted to write this post in explaining the beauty of a friendship steeped in chronic illness.

To my friends with chronic illnesses:

Thank you -

For understanding that when I say I'm having a 'bad day,' I'm really not feeling well but trying to be brave. For sending me funny pictures and sweet cards in the mail. For never replacing true empathy with an easy platitude.

Thank you for seeing the strength in my struggles, the determination in my pain, the resilience in my scars. For knowing that I am not my disease, but like a tree with a missing limb, I am whole even if my body is not.

I am better for being your friend - better for sharing my story with you and better for listening patiently to yours. I am so full of everything good because of your willingness to hear me when I'm terrified and upset, to celebrate my triumphs when I push on, to let me have a moment of fear before you tell me I can do anything.

We are not friends because we are sick - it may be how we found each other, but we are friends because we are puzzle pieces that click together, choruses to the same song, hands that were meant to hold the other. I look at you and see you, not your disease, not your pills, not your doctors, not your prognosis. We see one another when sometimes everyone else can only see the mask.

I hurt when you hurt, but I will always be there for you, just as you are there for me.

This is a thank you, a celebration, a marking of how much your friendship means to me. Words will never do this justice, but I wanted to try.

For now and for always, thank you.

Jennie


Step up

I have been meaning to write this post for a while but the thought of sharing my voice felt a bit self-glorifying so I held back, until now.  I realize that I may not be the only one holding back, so I decided to open up about getting involved in case others are feeling similar.  That is, wanting to give back maybe, somehow, not certain how, but also not ready to or feeling any desire to rally a crowd or become a spokesperson of any kind, any time soon.

 

I was diagnosed with ulcerative colitis 11 years ago, at age 16.  I have worked on research studies coincidentally linked with IBD since I graduated college and am currently working alongside a lot of big-shots in IBD research while getting my Master’s in counseling.  Speaking about my disease comes easily, trying to create a buzz about it does not.

 

For months I have been contemplating why I am not more interested, more invested in becoming more involved.  But what I also have been questioning is what it means to be involved and at what level it is acceptable.  Whether it is participating in a research study, writing about your experiences, sharing your story with a friend or broadly campaigning for awareness; being involved with a disease that has debilitated you in some way can seem daunting, overwhelming.  Why would I want to think about my disease any more than I have to?  Doesn’t thinking and stewing about this condition only make things worse?  Sure it can.  So if getting involved doesn’t feel right for you, at this time in your life, at this stage in your development or at this phase of your condition, that is OKAY.  Getting involved should make you feel comfortable and empowered.

 

This reminds me of the times I practiced meditation when I was really sick.  I did not focus on or contemplate my disease, no.  Instead, I visualized light radiating above my head where I pretended I was HEALTHY, that I was healing. I did better forgetting I was in pain, had chronic bloody diarrhea and had to eat a limited diet.

 

A friend recently shared an article with me called Engagement in advocacy: Not an all or nothing thing.  This resonated with me.  People considering getting involved come from all walks of life. They might be sick or in remission, they might be emerging from or deep within depression, they might be moving on with their lives happily and healthily and never looking back at the disease, they might be graduating from high school, college or grad school, they might be committed to another cause (just as worthy), they might be mothers of other children, grandparents, friends, doctors or researchers who wish they could do it all but don’t have the time or resources, they might have more skills and resources or less than others, and they might have limited or unlimited availability for whatever reason.

 

No single situation or story is the same.

 

A spectrum of ways to be involved, which encourage and empower every person at any stage to jump in, will welcome more people into the fold and build a community that represents everyone’s uniqueness, as well as our commonalities.

 

I encourage each person to consider what makes them comfortable. Your voice, your experience, your time has value however you choose to share it.

 

[Editor's note: This post was shared by Elizabeth Monti Sullivan. Liz works at the James M. Anderson Center for Health Systems Excellence leading efforts toward establishing a mentoring program and coordinates health care innovations like Passive PRO as part of C3N Project team.]


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