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Integrating Practice and Community Integrating Practice and Community Programs to Improve HealthPrograms to Improve Health

J. Lloyd Michener, MDJ. Lloyd Michener, MDProfessor and ChairProfessor and Chair

Department of Community and Family MedicineDepartment of Community and Family MedicineDirector, Duke Center for Community ResearchDirector, Duke Center for Community Research

Duke University School of MedicineDuke University School of MedicineAcademyHealth Annual Research MeetingAcademyHealth Annual Research Meeting

June 9, 2008June 9, 2008Washington, DCWashington, DC

Community Engagement - Takes Structure:Community Engagement - Takes Structure:The Duke Center for Community Research (DCCR)The Duke Center for Community Research (DCCR)Moving the Community from Subject to Moving the Community from Subject to

Collaborative PartnerCollaborative Partner

Goal:Goal:

Improve the health of the community Improve the health of the community through:through:

——Community engagement in Community engagement in researchresearch

——Integration of practices into Integration of practices into research structureresearch structure

——Linking communities, practices, Linking communities, practices, researchersresearchers

Components:Components:

1.1. Community Research Liaison Center Community Research Liaison Center

2.2. Community Health Research Community Health Research Training CenterTraining Center

3.3. Electronic Health Record Electronic Health Record

DTMI Faculty Leadership

DTMI Administration

DCCRDCRIDTRI

Oddone (K30), Bastian (T32), Hamilton (K12)

McKinney, Burks, McHutchison, Turner

Cuffe, McKinney, Szczech

St. Geme, Li, Benjamin

Cooke-Deegan, Beskow

George

Pietrobon, Krishnan, Ahmad, Cuttechia

Ginsburg, Weinhold, Kurtzberg, Guilak, Charles, Dewhirst, Toone, Hauser

Gilliss

Sullenger Harrington, Schulman, Peterson, McHutchison

Michener, Yaggy,Gilliss, Miranda

DTMI Administration

DCCRDCRIDTRI

Oddone (K30), Bastian (T32), Hamilton (K12)

McKinney, Burks, McHutchison, Turner

Cuffe, McKinney, Szczech

St. Geme, Li, Benjamin

Cooke-Deegan, Beskow

George

Pietrobon, Krishnan, Ahmad, Cuttechia

Ginsburg, Weinhold, Kurtzberg, Guilak, Charles, Dewhirst, Toone, Hauser

Gilliss

Sullenger Harrington, Schulman, Peterson, McHutchison

Michener, Yaggy,Gilliss, Miranda

DTMI Administration

DCCRDCRIDTRI

Education and Training

DCRU

Duke as a Site

Pediatrics

Ethics

Biostatistics

Biomedical Informatics

Core Laboratories

Nursing

New molecule

Preclinical dev.

First-in-human

Phase II/III

Application in the communityNew molecule

Preclinical dev.

First-in-human

Phase II/III

Application in the community

DTMI Organizational Structure DTMI Faculty Leadership

DTMI Administration

DCCRDCRIDTRI

Oddone (K30), Bastian (T32), Hamilton (K12)

McKinney, Burks, McHutchison, Turner

Cuffe, McKinney, Szczech

St. Geme, Li, Benjamin

Cooke-Deegan, Beskow

George

Pietrobon, Krishnan, Ahmad, Cuttechia

Ginsburg, Weinhold, Kurtzberg, Guilak, Charles, Dewhirst, Toone, Hauser

Gilliss

Sullenger Harrington, Schulman, Peterson, McHutchison

Michener, Yaggy,Gilliss, Miranda

DTMI Administration

DCCRDCRIDTRI

Oddone (K30), Bastian (T32), Hamilton (K12)

McKinney, Burks, McHutchison, Turner

Cuffe, McKinney, Szczech

St. Geme, Li, Benjamin

Cooke-Deegan, Beskow

George

Pietrobon, Krishnan, Ahmad, Cuttechia

Ginsburg, Weinhold, Kurtzberg, Guilak, Charles, Dewhirst, Toone, Hauser

Gilliss

Sullenger Harrington, Schulman, Peterson, McHutchison

Michener, Yaggy,Gilliss, Miranda

DTMI Administration

DCCRDCRIDTRI

Education and Training

DCRU

Duke as a Site

Pediatrics

Ethics

Biostatistics

Biomedical Informatics

Core Laboratories

Nursing

New molecule

Preclinical dev.

First-in-human

Phase II/III

Application in the communityNew molecule

Preclinical dev.

First-in-human

Phase II/III

Application in the community

DTMI Organizational Structure

Regulatory Affairs

Project Leaders and the Portal Office

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Leading Causes of Death in Leading Causes of Death in DurhamDurham, NC, NCAge-adjusted cancer death rates

100

150

200

250

300

350

1999-2003 2000-2004 2001-2005

Rate

per

100,0

00

Total Durham population North CarolinaUS Forsyth CountyGuilford County Mecklenburg County

Age-adjusted heart disease death rates

100

120

140

160

180

200

220

240

260

280

300

1999-2003 2000-2004 2001-2005

Rate

per

100,0

00

Durham North CarolinaUS Forsyth CountyGuilford County Mecklenburg County

Published in the 2007 Durham County Health Assessment, Data source: NC State Center for Health Statistics, County Health Data Book (http://www.schs.state.nc.us/SCHS/data/databook/) * Note: The US rates were

measured differently than NC state data, therefore interpret with caution.

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Community EngagementCommunity Engagement

Takes time and Takes time and persistencepersistence

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Community Engagement - a Diversity of Partners Community Engagement - a Diversity of Partners

Lincoln Community Health Lincoln Community Health Center (subsidized by DUHS)Center (subsidized by DUHS)

Durham County Health Durham County Health DepartmentDepartment

Wake CapitalCare Collaborative Wake CapitalCare Collaborative

Durham County Department of Durham County Department of Social ServicesSocial Services

The Durham CenterThe Durham Center

Senior PharmAssistSenior PharmAssist

Durham Housing AuthorityDurham Housing Authority

Durham Public SchoolsDurham Public Schools

El Centro HispanoEl Centro Hispano

Durham CAARESDurham CAARES

Faith-based organizationsFaith-based organizations

Duke University Hospital and Duke University Hospital and Health SystemHealth System

Duke University School of Duke University School of NursingNursing

Duke Dept of Community and Duke Dept of Community and Family MedicineFamily Medicine

Duke Dept of PediatricsDuke Dept of Pediatrics

Duke Dept of OB-GYNDuke Dept of OB-GYN

Duke Dept of PsychiatryDuke Dept of Psychiatry

Durham Regional HospitalDurham Regional Hospital

Duke Center on AgingDuke Center on Aging

Duke Department of MedicineDuke Department of Medicine

Duke Department of Duke Department of OphthalmologyOphthalmology

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Community Engagement - a Diversity of Programs Community Engagement - a Diversity of Programs and Sitesand Sites

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Clinical Networks – Duke SitesClinical Networks – Duke Sites

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Primary Care Research NetworkPrimary Care Research Network

The Primary Care Research Consortium is:• a primary care research network for academic, community, Veteran's Affairs (VA), and managed-care practices within the Duke Health System and surrounding communities. • includes 25 practices in 8 counties in North Carolina• represents more than 150 primary-care clinicians caring for more than 250,000 patients, with access to a total population of 1.2 million. • since 1997, the PCRC has conducted over 50 studies enrolling more than 3000 patients.

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Integrating Community Programs and PracticesIntegrating Community Programs and Practices

Bring in all who serve the same Bring in all who serve the same populationpopulation

Analyze populations, practices, Analyze populations, practices, and neighborhood dataand neighborhood data

Go to patient’s home and listen; Go to patient’s home and listen; asking open ended questionsasking open ended questions

Measure impact & qualityMeasure impact & quality

Adjust, ask for feedback on a Adjust, ask for feedback on a continuing basiscontinuing basis

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Durham Community Health Network and Durham Community Health Network and 5 County Community Care 5 County Community Care 35,000 Medicaid patients, Durham (DCHN), Vance, Granville, Warren and Person Counties (5 County) in 31 primary care practices

primarily women and children, largely African-American, growing Latino population

Community Partners:

County health departmentsState of NCCounty departments of social services

Practice Partners:

8 primary care practices in Durham County

•Local hospitals, ED’s and urgent care

•Duke: CFM, Peds, OB-GYN, DUH, DRH,

DHTS

Clinical Outcomes (State):•34% lower hospital admission rates•8% lower ED rate

Financial Outcomes (State):•24% lower average episode cost for children ($687 v $853)•$3.5 million/yr for asthma management•$2.1 million/yr for diabetes management•$60 million in SFY03•$124 million in SFY04

Total:

Since 2000, serving 350 patients, average age 70 who have multiple chronic conditions

44% have mental illness

All are home bound 84% are African-American; many with low to no

family support Low literacy; illiterate

Outcomes Ambulance costs ↓ 49% ER costs ↓ 41% Inpatient costs ↓ 68% Prescription costs ↑ 25% Home health costs ↑ 52%

Just for UsJust for Us

Community Partners:City of Durham, Housing AuthorityLincoln Community Health CenterDurham Council on SeniorsArea Mental Health AgencyDurham County Health DepartmentDurham County Department of Social Services

Practice Partners:Duke CFM, SON, DUH, DRH, Center for Aging, Department of Psychiatry

All patients with hypertension 79% ≤ 140/90Diabetics with hypertension 84% ≤ 140/90

• Durham County Uninsured: Latinos• Newly immigrated, from Mexico and Central America• No knowledge of health system; high risk behaviors • Community-based, bicultural support• Medicaid outreach • 10,800 enrolled to date; 5,500 active

LATCHLATCH

Decreased ED costsDecreased ED costsPercent ED Visits (Weighted)

0.250.2

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

Year 2(2004) Year 3(2005)Time

Per

cen

tag

e

Average ED Visits per Person (Weighted)

0.390.3

00.10.20.30.40.50.60.70.80.9

1

Year 2 (2004) Year 3 (2005)

Time

Community Partners:

El Centro Hispano

Durham County Health Department

Durham County Department of Social Services

Lincoln Community Health Center

Catholic Charities

Practice Partners:Planned Parenthood of Central NC

City of Durham, Parks and Recreation

DUH

DRH

CFM

SON

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Community-Wide Integration:Community-Wide Integration:A Work in ProgressA Work in Progress

Cabarrus County &

KannapolisSchools

Cabarrus Health Alliance

Carolinas Health Care System

CMC NortheastCastle & Cooke

Murdock

HealthyCabarrus

Cabarrus Family

Medicine

Churches

NovantHealthcare

CommunityFree Clinic

Rotary

CommunityRegistry

IT (EMR)

NE PhysicianNetwork

ResearchIRB

DiseaseManagement

CarolinaPhysicians

Network

Presbyterian Novant

Medical Group CommunityCare Plan

ResearchIRB

IT (EMR)

IT (EMR)

ResearchIRB

Private MDs

FQHCs(McGill &

Logan)

PastoralCare

LocalEmployers

UnitedWay

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Durham County ProjectsDurham County Projects

Pilot projects to see if teams of community groups, clinicians, and researchers can improve health

$ 1 million for planning

RFA for pilot projects to be released Summer 2008. Requirements:

1. Input, support, and commitment from community 1. Input, support, and commitment from community

2. Well-integrated design for prevention/care; 2. Well-integrated design for prevention/care;

3. Budget that demonstrates effective use of resources; 3. Budget that demonstrates effective use of resources;

4. Evaluation plan that establishes measurable markers4. Evaluation plan that establishes measurable markers

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A new role for academic health centers: Improving A new role for academic health centers: Improving the health of communitiesthe health of communities

Me

dic

al C

are

CommunityAna

lysi

s an

d Red

esig

n

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The Duke Center for Community Research (DCCR)The Duke Center for Community Research (DCCR)Goal: Improve the health of the community throughGoal: Improve the health of the community through

Community engagement in researchCommunity engagement in researchIntegration of practices into research structureIntegration of practices into research structureLinking communities, practices, researchersLinking communities, practices, researchers

Components:Components:

1.1. Community Research Liaison Center Community Research Liaison Center— 23 grants funded, submitted or under development; 14 community-23 grants funded, submitted or under development; 14 community-

wide health committees staffedwide health committees staffed

2.2. Community Health Research Training Center Community Health Research Training Center— Required training for clinicians and researchers launched; (initial Required training for clinicians and researchers launched; (initial

module completed by almost 700 individuals to date); two more in module completed by almost 700 individuals to date); two more in preparationpreparation

3.3. Electronic Health Record Electronic Health Record

4.4. Demonstration Projects Demonstration Projects

www.aamc.org/mededportal go to “Find Resources”; enter go to “Find Resources”; enter keyword: community engaged researchkeyword: community engaged research