The Duke Center for Community Research: Moving the Community from Subject to Collaborative Partner AcademyHealth Annual Meeting June 5, 2007 J. Lloyd Michener,

The Duke Center for Community Research: Moving the Community from Subject to Collaborative Partner

AcademyHealth Annual MeetingJune 5, 2007

J. Lloyd Michener, MDDirector, Duke Center for Community Research, DTMIProfessor 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 statusThe US is approximately equal to Cuba (and worse than several dozen other countries) in terms of the health of its citizensA 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 EngagementTogether, with community partners we Ask and listenAnalyze health care utilization and costsExplore barriers to appropriate careIdentify partner needs and resourcesPlan/redesign services Track outcomes, share accountability

Principles of Community EngagementProposed projects should be based on a need identified by Duke and the community that is beneficial to the community.Scope and time frame of project should be clear to the community. Partners must be willing to commit time and resources to the project. Partners must trust each other and build mutual respect while learning from each others perspectives.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. 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. 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 EngagementQuestions:Who?What?Where?When?Why?How and how much?MethodData collection quantitative and qualitative

Durham Community Health Network and 4 County Community Care Partners:County health departmentsState of NC: Community Care of NCPrimary care practices

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 County departments of social services

Local hospitals, EDs and urgent care

Duke: CFM, Peds, OB-GYN, DUH, DRH, DHTS

Durham Community Health Network and 4 County Community CareTarget patients by condition & provider referral Teams of community health workers, DSS social workers, nurses work with patients at homeOffer patient education, patient support, system navigation, and self-management skill trainingElectronically linked between practices, hospitals, DSS, Health Depts., and the teams

Just for Us: Improved health/strong outcomes Clinical All patients with hypertension79% 140/90Diabetics with hypertension84% 140/90UtilizationAmbulance 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 elementary1 high schoolCommunity Centers2 neighborhood clinics

Outcomes80% of school visits would have been ER visits90-95% of school clinic visits result in child returning to class rather than being sent home

Net cost/visit$8.24

Example 5Dental Van

The Duke Center for Community Research (DCCR)Goal:Improve the health of the communityCommunity engagement in researchInclusion of practices in researchLinking communities, practices, researchersGovernance:Community Advisory BoardExecutive Steering CommitteeComponents: Research Training CenterResearch Liaison CenterElectronic Health RecordMoving the Community from Research Subject to Collaborative Partner

DCCR Community Research Liaison CenterConnect Duke and local communities, practices, and organizations Outreach and training to assist communities with data and to connect communities with researchersA 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 CenterTrain and prepare researchers and learners to work successfully with communitiesElectronic training modulesOn-site training programsModules in Community Engagement in Research are under developmentConduct formal regulatory training and testing for community engagement

Personal Health Record (PHR)

New Challenges Require New SolutionsSolutions that Combine Innovation with Community Engagement

LATCHDurham County Uninsured: Latinos, 40% of uninsuredNewly immigrated, from Mexico, South and Central AmericaNo knowledge of health system; high risk health behaviors Community-based, bicultural navigation and support team, enrollment through El CentroMedicaid outreachPartners: El Centro HispanoDurham County Health DepartmentDurham County Department of Social ServicesLincoln Community Health CenterCatholic Charities

Planned Parenthood of Central NCCity of Durham, Parks and RecreationDUHDRHCFMSON

LATCH: Outcomes at 3 years9,000 uninsured Durham Latinos25% decrease in ED use among enrollees235 considered ineligible enrolled in Medicaid80% now have a primary care providerHelps DUHS clarify charity policies, add bilingual billing staff, and engage with partners

Walltown and Lyon Park ClinicsDuke-Durham Neighborhood Partnership:Neighborhoods ask for access to carePopulation: African-American, new Latino population, low-income, transient, uninsuredHealth characteristics: high ED use; inconsistent primary care, high risk health behaviors; substance abuse; depression/anxietyPartners: Calvary Baptist MinistriesWalltown Neighborhood AssociationPAC-2PAC-3 Lincoln Community Health CenterPlanned Parenthood of Central NCCommunity and Family Life and Recreation Center of the West End, IncSelf-Help, IncDuke Community Affairs Duke Community RelationsDUHCFM

Neighborhood ClinicsKeep costs low, easy access, locating clinics in neighborhood settings, NP/PAs as providersDuke 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 EDHigh patient satisfaction 4.7/5.0

Thanks for the opportunity to share how those of us at Duke are working to engage with our local communities, and through that engagement, improve the health of the community.

A bit of background -Duke is a big medical center in a county of about 250,000. Were the biggest employer by far, and also the dominant medical provider.

Durham has about 4 times more doctors and hospital beds than the national average, but is in the bottom 20% of the states in many of the health statistics.

If there has ever been a demonstration that doctors, nurses, and hospitals are essential but not sufficient for health, were it.

But it also raises the question of what else is needed. Or, to put it another way,How can an academic medical center and university collaborate with its community so as to improve health?

The map on the left again shows the distribution of births in 2001. On the right, we can see the spatial distribution of some community resources relevant for new mothersdoctors offices and day care facilities. Duke PartnersDuke Peds (Dennis Clements)Duke OB-GYNDuke Outpatient ClinicDuke HospitalDRHDuke Urgent CareClinical Informatics (David Lobach)Administration (Yaggy)Examples - Schools told us what they neededdental service - dental pain #1 reason for school absence- mobile dental services