1 Integrating Practice and Community Programs to Improve Health J. Lloyd Michener, MD Professor and Chair Department of Community and Family Medicine Director, Duke Center for Community Research Duke University School of Medicine AcademyHealth Annual Research Meeting June 9, 2008 Washington, DC

Community Engagement - Takes Structure: The Duke Center for Community Research (DCCR) Moving the Community from Subject to Collaborative Partner  Goal: Improve the health of the community through: —Community engagement in research —Community engagement in research —Integration of practices into research structure —Integration of practices into research structure —Linking communities, practices, researchers —Linking communities, practices, researchers  Components: 1. Community Research Liaison Center 2. Community Health Research Training Center 3. Electronic Health Record Regulatory Affairs Project Leaders and the Portal Office

3 Leading Causes of Death in Durham, NC Published in the 2007 Durham County Health Assessment, Data source: NC State Center for Health Statistics, County Health Data Book ( * Note: The US rates were measured differently than NC state data, therefore interpret with caution.

4 Community Engagement  Takes time and persistence

5 Community Engagement - a Diversity of Partners  Lincoln Community Health Center (subsidized by DUHS)  Durham County Health Department  Wake CapitalCare Collaborative  Durham County Department of Social Services  The Durham Center  Senior PharmAssist  Durham Housing Authority  Durham Public Schools  El Centro Hispano  Durham CAARES  Faith-based organizations  Duke University Hospital and Health System  Duke University School of Nursing  Duke Dept of Community and Family Medicine  Duke Dept of Pediatrics  Duke Dept of OB-GYN  Duke Dept of Psychiatry  Durham Regional Hospital  Duke Center on Aging  Duke Department of Medicine  Duke Department of Ophthalmology

6 Community Engagement - a Diversity of Programs and Sites

7 Clinical Networks – Duke Sites

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9 Primary Care Research Network The Primary Care Research Consortium is: a primary care research network for academic, community, Veteran's Affairs (VA), and managed-care practices within the Duke Health System and surrounding communities. includes 25 practices in 8 counties in North Carolina represents more than 150 primary-care clinicians caring for more than 250,000 patients, with access to a total population of 1.2 million. since 1997, the PCRC has conducted over 50 studies enrolling more than 3000 patients.

10 Integrating Community Programs and Practices  Bring in all who serve the same population  Analyze populations, practices, and neighborhood data  Go to patient’s home and listen; asking open ended questions  Measure impact & quality  Adjust, ask for feedback on a continuing basis 10

Durham Community Health Network and 5 County Community Care  35,000 Medicaid patients, Durham (DCHN), Vance, Granville, Warren and Person Counties (5 County) in 31 primary care practices  primarily women and children, largely African-American, growing Latino population Community Partners: County health departments State of NC County departments of social services Practice Partners: 8 primary care practices in Durham County Local hospitals, ED’s and urgent care Duke: CFM, Peds, OB-GYN, DUH, DRH, DHTS Clinical Outcomes (State): 34% lower hospital admission rates 8% lower ED rate Financial Outcomes (State): 24% lower average episode cost for children ($687 v $853) $3.5 million/yr for asthma management $2.1 million/yr for diabetes management $60 million in SFY03 $124 million in SFY04 Total:

  Since 2000, serving 350 patients, average age 70 who have multiple chronic conditions   44% have mental illness   All are home bound   84% are African-American; many with low to no family support   Low literacy; illiterate Outcomes  Ambulance costs↓ 49%  ER costs↓ 41%  Inpatient costs↓ 68%  Prescription costs↑ 25%  Home health costs↑ 52% Just for Us Annual Income $7,000 _ 25% Rent $5, / year Community Partners: City of Durham, Housing Authority Lincoln Community Health Center Durham Council on Seniors Area Mental Health Agency Durham County Health Department Durham County Department of Social Services Practice Partners: Duke CFM, SON, DUH, DRH, Center for Aging, Department of Psychiatry All patients with hypertension79% ≤ 140/90 Diabetics with hypertension84% ≤ 140/90

Durham County Uninsured: Latinos Newly immigrated, from Mexico and Central America No knowledge of health system; high risk behaviors Community-based, bicultural support Medicaid outreach 10,800 enrolled to date; 5,500 active LATCH Decreased ED costs Community Partners: El Centro Hispano Durham County Health Department Durham County Department of Social Services Lincoln Community Health Center Catholic Charities Practice Partners: Planned Parenthood of Central NC City of Durham, Parks and Recreation DUH DRH CFM SON

14 Community-Wide Integration: A Work in Progress Cabarrus County & Kannapolis Schools Cabarrus Health Alliance Carolinas Health Care System CMC Northeast Castle & Cooke Murdock Healthy Cabarrus Family Medicine Churches Novant Healthcare Community Free Clinic Rotary Community Registry IT (EMR) NE Physician Network Research IRB Disease Management Carolina Physicians Network Presbyterian Novant Medical Group Community Care Plan Research IRB IT (EMR) Research IRB Private MDs FQHCs (McGill & Logan) Pastoral Care Local Employers United Way

15 Durham County Projects   Pilot projects to see if teams of community groups, clinicians, and researchers can improve health   $ 1 million for planning   RFA for pilot projects to be released Summer Requirements: 1. Input, support, and commitment from community 2. Well-integrated design for prevention/care; 3. Budget that demonstrates effective use of resources; 4. Evaluation plan that establishes measurable markers

16 A new role for academic health centers: Improving the health of communities Medical Care Community Analysis and Redesign

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The Duke Center for Community Research (DCCR) Goal: Improve the health of the community through Community engagement in research Integration of practices into research structure Linking communities, practices, researchers  Components: 1. Community Research Liaison Center — 23 grants funded, submitted or under development; 14 community- wide health committees staffed 2. Community Health Research Training Center — Required training for clinicians and researchers launched; (initial module completed by almost 700 individuals to date); two more in preparation 3. Electronic Health Record 4. Demonstration Projects go to “Find Resources”; enter keyword: community engaged research