Cheshire Medical CEO readies for retirement, reflects on long career

And as he approaches his retirement later this month, his feelings are mixed.

“It’s kind of exciting to think about doing something different day to day,” Caruso, 64, said. “But then, when I think about the longer-term things that Cheshire has as opportunities, it makes me a little bit sad because I won’t be part of that.”

The Sentinel caught up with Caruso before his upcoming last day at the Dartmouth Health affiliate (May 26) to talk about his career, what he’s learned from it and the future of health care.

Caruso started at Cheshire Medical as a family medicine physician in 1992. He’s led the hospital since 2015 — the same year it joined the Dartmouth Health system — while also continuing to treat about 200 primary care patients.

During his time at the helm, Caruso oversaw the growth in provider numbers from about 75 to 242, which increased Cheshire Medical’s complexity of care and services. The hospital has roughly 1,500 employees and serves 47,000 patients from New Hampshire and Vermont.

That expansion, Caruso said, is what he’s most proud of during his time as CEO.

He has also helped launch Cheshire Medical’s family medicine residency program. Starting in 2024, six residents are scheduled to join the three-year program at the hospital’s Maple Avenue facility.

This is another milestone for Caruso, who said the program stems from his core beliefs as a health care provider.

“To me, it’s all about how do I actually give [people access to] the thing that I believe is most important in their health, which is to have a primary care physician that they can trust,” he said.

But, he also acknowledged that, while this new initiative is important, more needs to be done to address the ongoing primary care shortage in New Hampshire and beyond.

The shortage — exacerbated by the COVID-19 pandemic — is one of the greatest challenges affecting the hospital and health care, according to Caruso.

It’s estimated that New Hampshire will need an additional 333 primary care physicians by 2030, according to a report from the D.C.-based Robert Graham Center, which provides research on primary care.

Because of Cheshire Medical’s rural location, Caruso said it’s difficult to persuade providers to move here, which is why the new residency program is so important.

“The other family medicine residency programs in our state are not really training rural family doctors or rural doctors who are primary care physicians, and so those are huge barriers,” he said.

Caruso added that he thinks the program will help with the need for primary care physicians locally. Even so, he added it will take “a while” for the program to have an impact on the Monadnock Region.

“We’re probably talking about six to 10 years before it actually replenishes what’s needed here for primary care physicians,” he said.

The lack of providers feeds into Cheshire Medical’s other big hurdle: finances.

Caruso said one of the largest drivers of expenses is having to hire travel nurses to fill the need.

He estimated the hospital pays between $35 and $50 per hour for a traditional registered nurse, but would pay about $150 per hour for a traveling one. Rates for travel nurses significantly increased during the pandemic, but have since stabilized nationally, according to a January report from Vivian Health, a national health care hiring marketplace.

“Right now, we have 64 travelers in this organization. We have an entire shift at night of travelers ... So the cost of those travelers is exorbitant,” Caruso said.

The workforce shortage has also affected nursing homes and long-term care facilities, he added, leaving patients at Cheshire Medical for longer than needed because they cannot be discharged.

On average, 20 percent of the hospital’s staffed beds are occupied by “custodial patients,” meaning they no longer meet the criteria for acute-level care, according to Cheshire Medical.

“We have multiple, multiple long-stay patients that consume really those limited nursing resources,” Caruso said. “And then we don’t have places to put people who are sick.”

Once a patient is considered custodial, the hospital no longer receives any payments from insurers or government payers, meaning Cheshire Medical absorbs those costs, according to a hospital spokesperson.

Because of all of these factors, Caruso said Cheshire Medical was losing about $3 million per month up until recently. Now, it’s just under $2 million. The hospital’s annual revenue is about $260 million.

“It’s not sustainable in health care, and so that’s happening in many, many places, but more particularly in rural environments,” he said. “Dartmouth is seeing the same thing, and they are in the same predicament in terms of their losses are huge.”

Caruso also commented on the ongoing federal investigation into the gallons of fentanyl solution stolen or otherwise unaccounted for at Cheshire Medical from September 2021 to last May.

In February 2022, an ICU nurse reported that she’d stolen hundreds of bags of fentanyl solution from the hospital, according to documents from the N.H. Office of Professional Licensure and Certification (OPLC). But following the nurse’s death that March, and after remedial measures were put in place, the documents state that drugs still went missing.

In connection with the months-long substance diversion, the OPLC disciplined Cheshire Medical’s chief nursing officer, pharmacist-in-charge/director of pharmacy and a pharmacist — none of whom are still employed by the hospital.

An investigation into the diversion by the Drug Enforcement Administration is ongoing, a spokeswoman for the federal agency said Monday.

Caruso said the incident forced the hospital to examine its processes and tighten them, and that he feels Cheshire Medical’s drug diversion prevention measures are in a “really good place” today. State officials conducted several surveys of those new protocols, he noted, and because of that he feels confident in them.

When asked how these new procedures differ from what was in place during the fentanyl-solution incident, a hospital spokesperson said there have been “significant enhancements” to those protocols throughout the organization.

Cheshire Medical has focused on prevention, such as through extensive training and education of clinical staff, hiring specialized drug diversion specialists and implementing new practices.

“Did we learn a lesson? Absolutely,” Caruso said. “But I think that we’re in a much better place than we’ve ever been before in my whole 30 years here in terms of how tightly managed narcotics [are] and where patients are safe.”

Caruso also acknowledged that “much more work still needs to be done” to best serve diverse patient populations. He explained Cheshire Medical does have programs in place through its Center for Population Health to help people access care and navigate the system, such as by providing translators.

“There is an entire process, even if someone comes into the [emergency department], that we can have translators on the spot ... ,” he said. “Most of the time, it’s the language barrier that’s huge.”

Moving forward, the hospital is still determining Caruso’s successor. His replacement had been narrowed down to three candidates as of this week, Caruso said, and he estimated someone would be chosen by early June.

A search committee — consisting of representatives from Cheshire Medical, its board of trustees and Dartmouth Health — will make a recommendation on Caruso’s successor, according to a hospital spokesperson. If agreed upon by Cheshire Medical’s board of trustees, that decision will then be passed on to Dartmouth Health President and CEO Dr. Joanne Conroy for final approval.

With his final weeks at Cheshire Medical ahead, Caruso said he is starting to say goodbye to patients and colleagues. That’s been pretty emotional, he admitted.

“You know, you see a 40-year-old gentleman that you’ve been seeing since he was 15 years old, and you see him start to get teary,” Caruso said. “That kind of gets to you.”

As for his immediate retirement plans, Caruso — who plans to stay in the area — will welcome his first grandchild, work on building a boat in northern Vermont and travel with his wife, Dr. Nancy Johnson, who will retire in July as a physician in the hospital’s outpatient physical medicine and rehabilitation department.

Otherwise, Caruso has only one goal in mind.

“My plans,” he said, “are not to do anything but enjoy myself.”