Traditional Model of Care
1000
New Models of Primary Care
800
250-217
113 primary care
65 CAM
21 outpatient care
J. Lloyd Michener, MD
Professor and Chair
Department of Community and Family Medicine
Director, Duke Center for Community Research
Primary Care
9-8
Hospital
1/1
Tertiary Care
Kerr White Health Care Ecology Model
Part I
Cost: Health Care in the U.S. is in Crisis
Figure 4. 47 Million Uninsured in 2005;
Increasing Steadily Since 2000
Number of uninsured, in millions
Per
Per Capita
Capita
Personal
Personal
Health
Health
Spending,
Spending,
US
US
$50,000
$50,000
$45,000
$45,000
$40,000
$40,000
$35,000
$35,000
$30,000
$30,000
$25,000
$25,000
$20,000
$20,000
$15,000
$15,000
$10,000
$10,000
$5,000
$5,000
$0
$0
$44,244
$44,244
40
40
$22,482
$22,482
56
56
60
60
35
35 35
33 35
33 33
31
31 33
43
42 43
41 42
40 40
40 41
39
39 40
44
44
45
44 45
41 44
40
40 40
40 41
47
46
46 47
20
20
$11,431
$11,431
$29
$80
$29 $80
1940
1940
1950
1950
$2,566
$1,059 $2,566
$346 $1,059
$143
$143 $346
1960
1960
1970
1970
1980
1980
1990
1990
2000
2000
1987
1987
2010
2010
HCFA (1992) adjusted to HCFA 1998 1010-year projections
"The life of a Family Physician"
0
0
$5,555
$5,555
2020
2020
2030
2030
1990
1990
1993
1993
1996
1996
1999*
1999*
2002
2002
2005
2005
2008
2008 2011
2011 2013
Projected
*1999–
*1999–2003 estimates reflect the results of followfollow-up verification questions and implementation of
Census 20002000-based population controls.
Note: Projected estimates for 2006–
2006–2013 are for nonelderly uninsured based on T. Gilmer and
R. Kronick,
” Health Affairs
Kronick, “It’
It’s the Premiums, Stupid: Projections of the Uninsured Through 2013,
2013,”
Web Exclusive, Apr. 5, 2005. Source: U.S. Census Bureau, March CPS
CPS Surveys 1988 to 2005.
1
The Graying of America
1995
2010
Males Females
12 8 4 0 4 8 12
Prevalence of Obesity & Diabetes in the U.S.
2000
Males Females
90+
80-84
70-74
60-64
70-74
60-64
50-54
50-54
40-44
30-34
40-44
30-34
20-24
20-24
10-14
10-14
< 10
< 10
Obesity
No Data
< 10%
10%10%-14%
≥ 20%
15%15%-19%
Diabetes
12 8 4 0 4 8 12
12 8 4 0 4 8 12
Millions
Millions
Millions
1990/1991
2030
Males Females
90+
80-84
No Data
Institute for the Future, Health and Health Care 2010 (2000)
< 4%
4%4%-6%
> 6%
Mokdad et al., JAMA 286:1195–
286:1195–1200, 2001
Hospitalization Rates Are Dropping
Hospitalization rates in primary care
1.8
1.8
From 1980 to 2004, US days of inpatient care per
thousand plummeted across all age groups:
1.6
1.6
1.4
1.4
1.2
1.2
11
Age
Under 15
Change
- 40%
1515-44
4545-64
- 60%
- 63%
65 and over
- 50%
Source: Agency for Healthcare Research and Quality, 2005 National
National Healthcare Report
"The life of a Family Physician"
72%
0.8
0.8
0.6
0.6
0.4
0.4
0.2
0.2
00
1978
1978 1979
1979 1980
1980 1981
1981 1985
1985 1989
1989 1990
1990 1991
1991 1992
1992 1993
1993 1994
1994
Admitted
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;8:261999;8:26-32.
2
Preventable admissions vary
New Models
Hospitalizations for Ambulatory Care Sensitive Conditions
Source:The Quality of Medical Care in the United States: A Report on the Medicare
Medicare
Program. The Dartmouth Atlas of Health Care 1999. The Center for the Evaluative
Clinical Sciences Dartmouth Medical School
New Models of Care
Innovative models
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
» MultiMulti-disciplinary teams in community settings
neighborhoodneighborhood-based clinics
schoolschool-based clinics
inin-home medical care and case management
» Designed and delivered together with
community partners
• hospitalists,
hospitalists, direct access
1/1
Tertiary Care
» Innovative financing built on partnerships
• hospitalists,
hospitalists, discharge to
primary care
Walltown and Lyon Park Clinics
» DukeDuke-Durham Neighborhood Partnership:
Neighborhoods ask for access to care
Population: AfricanAfrican-American, new Latino
population, lowlow-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
PACPAC-2
PACPAC-3
Lincoln Community Health Center
Planned Parenthood of Central NC
Community and Family Life and
Recreation Center of the West End, Inc
SelfSelf-Help, Inc
Duke Community Affairs
Duke Community Relations
DUH
CFM
"The life of a Family Physician"
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
3
Just for Us: Caring for Durham’
Durham’s Older Adults in
Public and Subsidized Housing
» 300 homehome-bound seniors and disabled adults in
Durham senior lowlow-income public housing,
average age, 71, mostly women, AfricanAfricanAmerican, <$7K annual income, care
fragmented
» Multiple chronic diseases, average 5 rxns,
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
"The life of a Family Physician"
4
Some areas admit, some don’
don’t
Medical Discharge Rates
Source:The Quality of Medical Care in the United States: A Report on the Medicare
Medicare
Program. The Dartmouth Atlas of Health Care 1999. The Center for the Evaluative
Clinical Sciences Dartmouth Medical School
Duke Translational Medicine Institute
1. Community Research Liaison Center
DTMI
Administration
DCRI
DTRI
DCCR
Education and Training
Ethics
» The connection between Duke and local
communities, practices, and organizations
A virtual library:
Pediatrics
— For researchers to learn about communities
— For community groups to learn about themselves
— For practices to identify opportunities for
improvement
Biomedical Informatics
Biostatistics
Nursing
Core Laboratories
Regulatory Affairs
Project Leaders and the Portal Office
Outreach and training to assist communities with
data and to connect communities with researchers
Duke as a Site
DCRU
New molecule
Preclinical dev.
First-in-human
Application in the community
Phase II/III
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 coco-variates
Meshing advanced laboratory data with long term
outcomes
» Produce rapid & measurable improvement of
community health status
» Can perform rapid turnturn-around intervention studies
(V.J. Dzau 2006)
"The life of a Family Physician"
5
http://communityhealth.mc.duke.edu/education/?/masterhealthscience
http://communityhealth.mc.duke.edu/education/?/masterhealthscience
"The life of a Family Physician"
6