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 Duke Medicine Strategy for Community Engagement Together, with community partners we… we… » Ask and listen » Analyze health care utilization and costs 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 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’ 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 backgrounds to share ideas without fear of ridicule or criticism. No blaming 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. » Explore barriers to appropriate care » Identify partner needs and resources » Plan/redesign services » Track outcomes, share accountability Community Engagement Questions: » Who? » What? » Where? » When? » Why? » How – and how much? 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^_^_^_^^_ m ^__ m ^_ ^_ ^_^ ^_ ^_ ^_ ^_ ^_ ^ ^_^_ _ _ ^ ^ _ _ ^ ^ m m ^_ ^^_^^^^_ _ ^ ^ ^_ ^^ ^^ m m m mm ^ ^ ^^^^^^^^ m ^^^^^ ^^^^ ^ ^ _ ^ _ ^_^_^^_ ^_ ^_ ^_ Legend ^_ 2001 Births Ñ F Doctors Offices Number of Neighborhood Births in 2001 m Day Care N W Central Durham Neighborhoods S 1 Durham Community Health Network and 4 County Community Care 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 Target patients by condition & provider referral • primarily women and children, largely African-American, growing Latino population • Teams of community health workers, DSS social workers, nurses work with patients at home • 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’ ED’s and urgent care • Offer patient education, patient support, system navigation, and selfself-management skill training • Electronically linked between practices, hospitals, DSS, Health Depts., and the teams Duke: CFM, Peds, Peds, OBOB-GYN, DUH, DRH, DHTS Just for Us: Caring for Durham’ Durham’s Older Adults in Public and Subsidized Housing Just for Us: Improved health/strong outcomes » 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 Clinical » Multiple chronic diseases, average 5 rxns, rxns, 44% also have mental conditions Utilization » Care delivered by NP/PA, SW, OT, PT, RD in home » Ambulance costs ↓ 49% » ER costs ↓ 41% » Inpatient costs ↓ 68% » Prescription costs ↑ 25% » Home health costs ↑ 52% 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 » All patients with hypertension 79% ≤ 140/90 » Diabetics with hypertension 84% ≤ 140/90 Source: State of North Carolina Division of Medical Assistance Outcomes Micro Clinics Example 3 & 4: » 4 NPNP-based school clinics —3 elementary —1 high school » Community Centers —2 neighborhood clinics » 80% of school visits would have been ER visits » 9090-95% of school clinic visits result in child returning to class rather than being sent home » Net cost/visit $8.24 2 Example 5 The Duke Center for Community Research (DCCR) » Dental Van Moving the Community from Research Subject to Collaborative Partner 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 Ethics Pediatrics Biomedical Informatics Biostatistics » Governance: Community Advisory Board Executive Steering Committee » Components: Research Training Center Research Liaison Center Electronic Health Record 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 Personal Health Record (PHR) DCCR Education and Training Nursing Core Laboratories Regulatory Affairs Project Leaders and the Portal Office Duke as a Site DCRU New molecule First-in-human Preclinical dev. Application in the community Phase II/III DCCR Community Health Research Training Center • Train and prepare researchers and learners to work successfully with communities Electronic training modules OnOn-site training programs Modules in Community Engagement in Research are under development • Conduct formal regulatory training and testing for community engagement New Challenges Require New Solutions… Solutions… …Solutions that Combine Innovation with Community Engagement 3 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 » CommunityCommunity-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 LATCH: Outcomes at 3 years Planned Parenthood of Central NC City of Durham, Parks and Recreation DUH DRH CFM SON Walltown and Lyon Park Clinics » DukeDuke-Durham Neighborhood Partnership: » 9,000 uninsured Durham Latinos Neighborhoods ask for access to care » 25% decrease in ED use among enrollees Population: AfricanAfrican-American, new Latino population, lowlow-income, transient, uninsured » 235 considered ineligible enrolled in Medicaid Health characteristics: high ED use; inconsistent primary care, high risk health behaviors; substance abuse; depression/anxiety » 80% now have a primary care provider » Helps DUHS clarify charity policies, add bilingual billing staff, and engage with partners 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 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 4