New Models of Primary Care
J. Lloyd Michener, MD
Professor and Chair
Department of Community and Family Medicine
Director, Duke Center for Community Research
Traditional Model of Care
1000
800
250-217
113 primary care
65 CAM
21 outpatient care
Primary Care
9-8
Hospital
1/1
Kerr White Health Care Ecology Model
Tertiary Care
Part I
Cost: Health Care in the U.S. is in Crisis
Per Capita
Personal
Health
Spending,
US
$50,000
$45,000
$40,000
$35,000
$30,000
$25,000
$20,000
$15,000
$10,000
$5,000
$0
$44,244
$22,482
$11,431
$29 $80
1940
1950
$143
1960
$2,566
$346 $1,059
1970
1980
1990
2000
$5,555
2010
HCFA (1992) adjusted to HCFA 1998 10-year projections
2020
2030
Figure 4. 47 Million Uninsured in 2005;
Increasing Steadily Since 2000
Number of uninsured, in millions
56
60
40
33
31 33
35 35
39 40 40
41
44
42 43
40 40 41
44 45
46 47
20
0
1987
1990
1993
1996
1999*
2002
2005
2008
2011
Projected
2013
*1999–2003 estimates reflect the results of follow-up verification questions and implementation of
Census 2000-based population controls.
Note: Projected estimates for 2006–2013 are for nonelderly uninsured based on T. Gilmer and
R. Kronick, “It’s the Premiums, Stupid: Projections of the Uninsured Through 2013,” Health Affairs
Web Exclusive, Apr. 5, 2005. Source: U.S. Census Bureau, March CPS Surveys 1988 to 2005.
The Graying of America
1995
2010
2030
Institute for the Future, Health and Health Care 2010 (2000)
Prevalence of Obesity & Diabetes in the U.S.
1990/1991
2000
Obesity
No Data
< 10%
10%-14%
15%-19%
 20%
Diabetes
No Data
< 4%
4%-6%
> 6%
Mokdad et al., JAMA 286:1195–1200, 2001
Hospitalization Rates Are Dropping
From 1980 to 2004, US days of inpatient care per
thousand plummeted across all age groups:
Age
Under 15
15-44
Change
- 40%
- 60%
45-64
65 and over
- 63%
- 50%
Source: Agency for Healthcare Research and Quality, 2005 National Healthcare Report
Hospitalization rates in primary care
1.8
1.6
1.4
1.2
1
72%
0.8
0.6
0.4
0.2
0
1978
1979
1980
1981
1985
1989
1990
1991
1992
1993
1994
Admitted
Source: Stafford RS, Saglam D, Causino N, Starfield B, Culpepper L, Marder WD,
Blumenthal. Trends in adult visits to primary care physicians in the United States.
Arch Fam Med. 1999;8:26-32.
Preventable admissions vary
Hospitalizations for Ambulatory Care Sensitive Conditions
Source:The Quality of Medical Care in the United States: A Report on the Medicare
Program. The Dartmouth Atlas of Health Care 1999. The Center for the Evaluative
Clinical Sciences Dartmouth Medical School
New Models
New Models of Care
1000
Community Care
800
• health education, advisors, care
managers, internet access, minute
clinics, urgent care
250-217
113 primary care
65 CAM
21 outpatient care
Primary Care
• teams, chronic care models
Hospital/secondary care
9-8
• hospitalists, direct access
1/1
Tertiary Care
• hospitalists, discharge to
primary care
Innovative models
 Multi-disciplinary teams in community settings
neighborhood-based clinics
school-based clinics
in-home medical care and case management
 Designed and delivered together with
community partners
 Innovative financing built on partnerships
Walltown and Lyon Park Clinics
 Duke-Durham Neighborhood Partnership:
Neighborhoods ask for access to care
Population: African-American, new Latino
population, low-income, transient,
uninsured
Health characteristics: high ED use; inconsistent primary care,
high risk health behaviors; substance abuse; depression/anxiety
Partners:
Calvary Baptist Ministries
Walltown Neighborhood Association
PAC-2
PAC-3
Lincoln Community Health Center
Planned Parenthood of Central NC
Community and Family Life and
Recreation Center of the West End, Inc
Self-Help, Inc
Duke Community Affairs
Duke Community Relations
DUH
CFM
Neighborhood Clinics
 Keep costs low, easy access, locating clinics in
neighborhood settings, NP/PAs as providers
 Duke Endowment, Duke University, Duke Hospital
 >10,000 visits projected for
FY07
 70% of visits are return
visits (continuity)
 37% of patients surveyed
would have gone to ED
 High patient satisfaction – 4.7/5.0
Just for Us: Caring for Durham’s Older Adults in
Public and Subsidized Housing
 300 home-bound seniors and disabled adults in
Durham senior low-income public housing,
average age, 71, mostly women, AfricanAmerican, <$7K annual income, care
fragmented
 Multiple chronic diseases, average 5 rxns, 44%
also have mental conditions
 Care delivered by NP/PA, SW, OT, PT, RD in
home
Partners:
City of Durham, Housing Authority
Lincoln Community Health Center
Durham Council on Seniors
Duke Center on Aging
Area Mental Health Agency
Durham County Health Department
Durham County Department of
Social Services
Duke CFM, SON, DUH, DRH, Center for
Aging, Psychiatry
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
—Integration of practices into research structure
—Linking communities, practices, researchers
 Components:
1. Community Research Liaison Center
2. Community Health Research Training Center
3. Electronic Health Record
A New Approach
 Understand the needs of your communities
 Identify the barriers to receiving care
 Test methods of improving access, outcomes,
and cost in your practices and communities
Some areas admit, some don’t
Medical Discharge Rates
Source:The Quality of Medical Care in the United States: A Report on the Medicare
Program. The Dartmouth Atlas of Health Care 1999. The Center for the Evaluative
Clinical Sciences Dartmouth Medical School
DTMI Organizational Structure
Duke Translational Medicine Institute
DTM
DTMI
Administration
DCRI
DTRI
DCCR
DTRI
Sullenger
Education and Training
Odd
Ethics
Pediatrics
Biomedical Informatics
P
Biostatistics
Nursing
Core Laboratories
Ginsburg, Weinho
Regulatory Affairs
Project Leaders and the Portal Office
Duke as a Site
DCRU
New molecule
Preclinical dev.
First-in-human
M
Application in the community
Phase II/III
1. Community Research Liaison Center
 The connection between Duke and local
communities, practices, and organizations
A virtual library:
— For researchers to learn about communities
— For community groups to learn about themselves
— For practices to identify opportunities for
improvement
Outreach and training to assist communities with
data and to connect communities with researchers
2. Community Health Research Training Center
 Train and prepare researchers to work
successfully with communities
Train and prepare learners/trainees to research
successfully with communities
Conduct formal regulatory training and testing for
community engagement
3. DCCR Electronic Health Record
 Covers citizens of Durham County
 Captures data for Durham County
 Develop analytic techniques using data from the
DSR
Dealing with co-variates
Meshing advanced laboratory data with long term
outcomes
 Produce rapid & measurable improvement of
community health status
 Can perform rapid turn-around intervention studies
(V.J. Dzau 2006)
http://communityhealth.mc.duke.edu/education/?/masterhealthscience