1. 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

2. 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

3. 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

4. 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.

5. Questions:  Who?  What?  Where?  When?  Why?  How – and how much? Method Data collection – quantitative and qualitative Community Engagement

7. Durham Community Health Network and 4 County Community Care Partners: County health departmentsCounty health departments State of NC: Community Care of NCState of NC: Community Care of NC Primary care practicesPrimary 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, ED’s and urgent care Local hospitals, ED’s and urgent care Duke: CFM, Peds, OB-GYN, DUH, DRH, Duke: CFM, Peds, OB-GYN, DUH, DRH, DHTS DHTS

8. 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 homeTeams of community health workers, DSS social workers, nurses work with patients at home Offer patient education, patient support, system navigation, and self-management skill trainingOffer patient education, patient support, system navigation, and self-management skill training Electronically linked between practices, hospitals, DSS, Health Depts., and the teamsElectronically linked between practices, hospitals, DSS, Health Depts., and the teams

9. 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, African- American, <$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 Durham County Health Department Durham County Department of Social Services Duke CFM, SON, DUH, DRH, Center for Aging, Psychiatry Partners: City of Durham, Housing Authority Lincoln Community Health Center Durham Council on Seniors Duke Center on Aging Area Mental Health Agency

10. Just for Us: Improved health/strong outcomes Clinical  All patients with hypertension79% ≤ 140/90  Diabetics with hypertension84% ≤ 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

11. Micro Clinics Example 3 & 4:  4 NP-based school clinics —3 elementary —1 high school  Community Centers —2 neighborhood clinics

12. 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

13. Example 5  Dental Van

14. The Duke Center for Community Research (DCCR)  Goal: Improve the health of the community Community engagement in research Inclusion of practices in research Linking communities, practices, researchers  Governance: Community Advisory Board Executive Steering Committee  Components: Research Training Center Research Liaison Center Electronic Health Record Moving the Community from Research Subject to Collaborative Partner Regulatory Affairs Project Leaders and the Portal Office

15. DCCR Community Research Liaison Center Connect Duke and local communities, practices, and organizationsConnect 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 themselvesFor community groups to learn about themselves For practices to identify opportunities for improvementFor practices to identify opportunities for improvement For researchers to learn about communitiesFor researchers to learn about communities

16. DCCR Community Health Research Training Center Train and prepare researchers and learners to work successfully with communitiesTrain 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 engagementConduct formal regulatory training and testing for community engagement

17. Personal Health Record (PHR)

18. New Challenges Require New Solutions… …Solutions that Combine Innovation with Community Engagement

20. 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 DUHDRHCFMSON

21. 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

22. 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-2PAC-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 DUHCFM

23. 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