The Duke Center for Community Research:
Moving the Community from Subject to
Collaborative Partner
AcademyHealth Annual Meeting
June 5, 2007
J. Lloyd Michener, MD
Director, Duke Center for Community Research, DTMI
Professor and Chair, Department of Community and Family Medicine
Can we Demonstrate that by Combining the
Resources of a Major University with the
Resourcefulness of a Community we can become
a model of health?
 Durham County is average for North Carolina in almost
every health statistic
(except that it has significantly more doctors and dentists per
population)
 North Carolina is in the bottom 20% of US states in survival
and functional status
 The US is approximately equal to Cuba (and worse than
several dozen other countries) in terms of the health of its
citizens
 A great hospital and a lot of doctors do not ensure good
health of the people who live in Durham County
Duke Medicine Strategy for Community
Engagement
Together, with community partners we…
 Ask and listen
 Analyze health care utilization and
costs
 Explore barriers to appropriate care
 Identify partner needs and resources
 Plan/redesign services
 Track outcomes, share accountability
Principles of Community Engagement
1.
Proposed projects should be based on a need identified by Duke
and the community that is beneficial to the community.
2.
Scope and time frame of project should be clear to the
community. Partners must be willing to commit time and
resources to the project.
3.
Partners must trust each other and build mutual respect while
learning from each other’s perspectives.
4.
A diverse range of community members and agencies need to
participate to ensure that proposed activities meet the needs of a
diverse population. All participants are considered experts.
5.
A safe environment exists for all participants of all backgrounds
to share ideas without fear of ridicule or criticism. No blaming or
judgments. Keep lines of communication open.
6.
Partners must be good stewards of project data and include the
community in outcome reporting and evaluation, potential
programmatic intervention, education opportunities, and future
program planning activities.
Community Engagement
Questions:
 Who?
 What?
 Where?
 When?
 Why?
 How – and how much?
Method
Data collection – quantitative and
qualitative
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Durham Community Health Network
and 4 County Community Care
• 35,000 Medicaid patients, Durham (DCHN), Vance, Granville,
Warren and Person Counties (4 County) in 31 primary care practices
• primarily women and children, largely African-American, growing
Latino population
• chronic disease, depression/anxiety, substance abuse, poor
medication compliance, health often not a first priority, transportation,
language, literacy, trust
Partners:
•
•
County health departments
•
State of NC: Community Care of NC •
•
Primary care practices
•
County departments of social services
Local hospitals, ED’s and urgent care
Duke: CFM, Peds, OB-GYN, DUH, DRH,
DHTS
Durham Community Health Network
and 4 County Community Care
Target patients by condition & provider referral
• Teams of community health workers, DSS
social workers, nurses work with patients at
home
• Offer patient education, patient support,
system navigation, and self-management skill
training
• Electronically linked between practices,
hospitals, DSS, Health Depts., and the teams
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
Just for Us: Improved health/strong outcomes
Clinical
 All patients with hypertension
79% ≤ 140/90
 Diabetics with hypertension
84% ≤ 140/90
Utilization
 Ambulance costs
↓ 49%
 ER costs
↓ 41%
 Inpatient costs
↓ 68%
 Prescription costs
↑ 25%
 Home health costs
↑ 52%
Source: State of North Carolina Division of Medical Assistance
Micro Clinics
Example 3 & 4:
 4 NP-based school clinics
—3 elementary
—1 high school
 Community Centers
—2 neighborhood clinics
Outcomes
 80% of school visits would have been ER visits
 90-95% of school clinic visits result in child
returning to class rather than being sent home
 Net cost/visit
$8.24
Example 5
 Dental Van
The Duke Center for Community Research
(DCCR)
DTMI to
Organizational
Moving the Community from Research Subject
CollaborativeStructure
Partner
 Goal:
Improve the health of the
community
Community engagement in
research
Inclusion of practices in
research
Linking communities,
practices, researchers
DTMI
Administration
DCRI
DTRI
Education and Training
Ethics
Pediatrics
Biomedical Informatics
Biostatistics
 Governance:
Community Advisory Board
Executive Steering Committee
 Components:
Research Training Center
Research Liaison Center
Electronic Health Record
DCCR
Nursing
Core Laboratories
Regulatory Affairs
Project Leaders and the Portal Office
Duke as a Site
DCRU
New molecule
Preclinical dev.
First-in-human
Application in the community
Phase II/III
G
DCCR Community Research Liaison Center
• Connect Duke and local communities,
practices, and organizations
Outreach and training to assist communities
with data and to connect communities with
researchers
A virtual library:
•
•
•
For community groups to learn about
themselves
For practices to identify opportunities for
improvement
For researchers to learn about communities
DCCR Community Health Research Training
Center
• Train and prepare researchers and
learners to work successfully with
communities
Electronic training modules
On-site training programs
Modules in Community Engagement
in Research are under development
• Conduct formal regulatory training and
testing for community engagement
Personal Health Record (PHR)
New Challenges Require New Solutions…
…Solutions that Combine Innovation with
Community Engagement
LATCH
 Durham County Uninsured: Latinos, 40% of
uninsured
 Newly immigrated, from Mexico, South and
Central America
 No knowledge of health system; high risk health
behaviors
 Community-based, bicultural navigation and
support team, enrollment through El Centro
 Medicaid outreach
Partners:
El Centro Hispano
Durham County Health Department
Durham County Department of
Social Services
Lincoln Community Health Center
Catholic Charities
Planned Parenthood of Central NC
City of Durham, Parks and Recreation
DUH
DRH
CFM
SON
LATCH: Outcomes at 3 years
 9,000 uninsured Durham Latinos
 25% decrease in ED use among
enrollees
 235 considered ineligible enrolled
in Medicaid
 80% now have a primary care
provider
 Helps DUHS clarify charity policies, add
bilingual billing staff, and engage with
partners
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