Durham Health Innovations:
City of Medicine,
Community of Health
Michelle J. Lyn, MBA, MHA
Assistant Professor
Chief, Division of Community Health
Department of Community and Family Medicine
Associate Director, Duke Center for Community Research
Our Context: A History of Collaboration and
an Opportunity to Lead…
Duke and Durham Collaboration:
A Few Examples…
 Community clinics
 School-based clinics
 Home care for elderly and/or disabled
 Care management teams
 Specialty Care Access
An Opportunity to Lead…
What we must address… Access, Cost, Quality
What we know….
— Most illness related to health behaviors
— Disease burden and practice patterns vary
What we believe….
Everyone deserves access to simple, proven measures to reduce
the risk of dying or losing function.
It is time to rethink the work, redesign the
Our Support
 Clinical and Translational Science Awards
(CTSA) of the National Institutes of Health (NIH)
 Duke Medicine
Duke Translational Medicine Institute
Duke Center for Community Research
Durham Health Innovations
The Fundamental Question…
What does it take to move the
health indicators for our ENTIRE
Oversight Committee
Rob Califf, MD, Director, DTMI and Vice Chancellor for
Clinical Research, Duke Medicine
Gayle B. Harris, MPH, Director, Durham County Health
MaryAnn Black, MSW, LCSW,
Associate Vice President, Office of
Community Relations, DUHS
Jackie Brown, Community
William Fulkerson, MD, Senior Vice
President, Clinical Affairs, DUHS
J. Lloyd Michener, MD, Chairman,
Department of Community & Family
Medicine and Director, Duke Center for
Community Research
Marie Lynn Miranda, PhD, Director,
Children’s Environmental Health Initiative,
Duke University Nicholas School of the
Catherine L. Gilliss, DNSc, RN,
FAAN, Dean, Duke University
School of Nursing and Vice
Chancellor for Nursing Affairs
Earl Phillips, Assistant Director,
Community Engagement, City of Durham
Ellen Holliman, Director, The
Durham Center
Pilar Rocha-Goldberg, Executive Director,
El Centro Hispano
Gerri Robinson, Director, Durham County
Department of Social Services
 Planning Grants
 An Interdisciplinary Duke-Durham Team
 Relevant Health Issue
 Engage Population Most Affected/Most At-Risk
 Alternative model of service/care
 Institutional Resources in Planning Activities
 Financial Model
 Evaluation Plan
 Dissemination Plan
Stage 1 by the numbers…
22 Duke-Durham teams submitted
Stage I Brief Proposals
413 team members –
237 representing Duke and
176 community partners (representing
90 community agencies/organizations
and businesses)
19 Duke-Durham teams moved to
Stage II
Stage II applications required
 Select co-team leaders from Duke and the
 Identify a project manager
 Propose, describe, and present evidence for an
innovative model of care (i.e., changes in the
structure or function of a service, system, or care
delivery setting).
 Detail how community partnerships would be
central to the planning process
Project Areas
 Adolescent Health
 HIV/STD/Hepatitis
 Asthma and Chronic
Pulmonary Disease
 Maternal Health
 Cancer
 Cardiovascular
 Diabetes
 Obesity
 Pain Management
and Substance
 Seniors Health
Adolescent Health
Adolescent Health Initiative (AHI)
 Team Co-Leads:
Kristin Ito, MD, MPH, Duke Department of Pediatrics
Nancy Kent, LCSW, The Durham Center
C. Nicole Swiner, MD, UNC Family Medicine
Yvonne Wasilewski, PhD, MPH, Center for Child and
Family Policy
 Project Managers:
May Alexander & Wendy Tonker, How’s that working?
Asthma and COPD
Innovative Approaches to Better Detect and Treat Asthma
and Chronic Obstructive Pulmonary Disease in Durham
(Breathe Easy Team)
 Team Co-Leads:
Monica Kraft, M.D., Duke Asthma, Allergy and Airway
Betty Masten, M.D., Lincoln Community Health Center
 Project Manager:
Rhonda Webb, M.S., Duke Asthma, Allergy and Airway
Cancer Prevention and Early Detection
A Partnership for Community Wellness in Durham, NC
Team Co-Leads:
 Victoria Seewaldt, M.D.,
Duke Pharmacology and
Cancer Biology, Cancer
Control and Prevention
 Sharon Elliot Bynum, RN,
BSN, MA, Ph.D., Healing
with CAARE, Inc.
 Anne Ford, M.D., Duke
Department of OB/Gyn
 Gustavo Montana, M.D.
Duke Radiation Oncology
 Vladirir Mouraviev, M.D., Ph.D.,
Duke Department of Surgery
 Marva Price, DrPH, RN, FAAN,
Duke University School of
 Stephanie Robertson, Duke
University Comprehensive
Cancer Center
 Valarie Worthy, R.N., Sister
Network, Durham/Triangle
Project Manager:
 Jeff Birnbaum, B.S.E., Duke
Department of Medical Oncology
Cardiovascular Disease
Vascular Intervention Project (VIP)
 Team Co-Leads:
Kevin L. Thomas, M.D., FACC, FAAC, Duke Division of
Cardiovascular Disease/Duke Clinical Research Institute
Sharon Elliott-Bynum, RN, MSN, Ph.D., Healing with
CAARE Inc., Jeanne Lucas Education and Wellness Center
 Project Manager:
Kristin Dossary, Duke Clinical Research Institute
Partnership IMPACTS Diabetes Outcomes
 Team Co-Leads:
Gloria Trujillo, M.D., Duke Department of Community
and Family Medicine
Kathryn Trotter, MSN, CNM, FNP, Duke University
School of Nursing
Michele Easterling, MPH, RD, Durham County Health
Nichole Weedon, MSW, P-LCSW, Durham County Dept.
of Social Services
 Project Manager:
Rachel Kuliani, MPH, Durham Health Innovations
HIV, STD and Hepatitis Prevention
and Care
Prevention and Treatment of HIV,STDs, and Hepatitis in
Durham County
 Team Co-Leads:
John Bartlett, MD, Duke Global Health Institute /
Infectious Disease Clinic
Arlene Sena, MD, MPH, Durham County Health
Department, UNC-CH Division of Infectious Diseases
 Project Managers:
Mary DeCoster, MPH, Durham County Health
Marc Kolman, MSPH, Piedmont Health Care Consortium
Maternal and Child Health
The Maternal and Child Health Intervention Group (MCH Group)
 Team Co-Leads:
Monique Chireau, M.D., MPH, Duke Department of Obstetrics
and Gynecology
Tamera Coyne-Beasley, MD, MPH, Community Health
Coalition / UNC-CH Dept. of Pediatrics and Internal Medicine
Sue McLaurin, M.Ed., PT, Community Health Coalition
Maria Small, MD, MPH, Duke Department of Obstetrics and
 Project Managers:
Tammy Bishop, RNC, MSN, Duke Department of Obstetrics
and Gynecology
Lottie Barnes, MPH, CHES, Community Health Coalition
Achieving Healthy Bodies for a Lifetime (AHL)
 Team Co-Leads:
David Reese, MBA, Chief Operating Officer, Inter-Faith
Food Shuttle
William Yancey, Jr. MD, MHS, Duke Department of
 Project Manager:
Jennifer McDuffie, PhD, General Internal Medicine,
Durham VAMC
Pain Management and Substance
Rethinking Pain: Collaborative Approaches to Address the
Relationship of Pain, Substance Abuse, and Psychiatric
 Team Co-Leads:
Fred Johnson, MBA, Duke Division of Community
Cathleen Melton, MD, Lincoln Community Health
 Project Manager:
Sarah Weaver, MPH, Duke Division of Community Health
Seniors Healthy in Place "HIP Seniors"
 Team Co-Leads:
Robin Ali, MD, PharmD, Duke Dept. of Community and
Family Medicine
Brenda Jamerson, PharmD, Duke Psychiatry and Behavioral
Sciences, Campbell University School of Pharmacy
Ellie McConnell, RN, PhD, GCNS, BC, Duke School of
Joan Pellettier, Triangle J Area Agency on Aging
Gina Upchurch, RPh, MPH, Senior PharmAssist
 Project Manager:
Carolyn Kroll, MA, CK Kroll & Associates. Inc.
Technical Assistance Cores
Data and Analysis
Plan Development
Michelle Lyn
Earl Phillips (City of Durham
Marie Lynn Miranda
Becky Freeman (Durham
Krishna Udayakumar
Casey Steinbacher (Durham
County Health Department)
County Chamber of Commerce)
 Alternative
models of
Housing and Development)
 Modeling
 Connecting to
other teams
 DSR and other
linked data
 Business data
 Business plan
 Data from teams
 Geospatial
Data confidentiality issues
Finding Common Ground
Elements of a Connected Care
1. Population Analysis and Risk Stratification
2. Metrics and Accountability
3. Care Management/Care Coordination
4. Communication
Common Elements Across Teams
Population Analysis and Risk
 People with or at high risk for health problems
 Risk stratification that accounts for health status,
socio-economic and environmental factors
 Assess neighborhood- and community-wide
health status and identify opportunities for health
Common Elements Across Teams
Metrics and Accountability
Collaboratively identify key measures to:
- determine extent of the health
- track progress
- inform decision-making and resource
Common Elements Across Teams
3. Care Management / Care Coordination
 Community health advocates
 Optimal use of all providers including specialist and
primary care physicians
 Care closer to people’s homes and neighborhoods
 Tight coordination of clinical services, home health,
hospice, pharmacists, respiratory therapy, etc.
 Opportunities for group visits, home visits, and use of
internet technology for health care strategies
Common Elements Across Teams
 Engage community input throughout the entire
 Leverage information technology and informatics
capabilities to facilitate improved communication
— across community and providers
— improve decision-making (via availability of
critical information, decision support tools, riskstratification tools)
— information & referral
Combining team efforts results in…
Care designed with communities and providers that optimizes the
use of non-traditional and traditional providers so that it is:
To home, neighborhood, school, workplace…
Individuals to health providers
Health providers to each other
Measurable performance with consequences
It is a fundamental redesign, not a substitution
model, not a “lesser” model
Challenges and Lessons Learned
 Each step of the way
 Through every process
 In each relational group
Next Steps…
What we have:
A shared understanding that we ALL have
a role to play in improving the health of
our community
What we need:
An open commitment by ALL of us that
improved health outcomes is a shared
goal and that ALL of us are willing to be
held accountable for our work toward
that goal
Next Steps…
What we must do:
– Continue to focus on engagement
– Achieve consensus on our expected outcomes
and how we will measure them
– Recognize this is not and should never be a
“one intervention fits all” approach
– Set realistic expectations of time – this is NOT
a short-term effort - it will require phases of
– Demonstrate the positive economic impact of
health-related activities
Our First Steps…
– Finish synthesizing the work of the teams
and incorporate YOUR input
– Expand the DHI Oversight Committee
– Provide project management, quantitative
support, and grant writing support to the
– Appoint an Informatics and Information
Technology Committee
– Appoint Implementation Team to
operationalize strategies and ensure
coordination of effort across the work of the
Poster Session:
A Discussion with DHI Participants

Team Co-Leads - Office of Community Relations