New Models of Primary Care

1. J. Lloyd Michener, MD Professor and ChairDepartment of Community and Family MedicineDirector, Duke Center for Community Research New Models of Primary Care

2. Traditional Model of Care Primary Care Hospital TertiaryCare Kerr White Health Care Ecology Model

3. Part ICost: Health Care in the U.S. is in Crisis HCFA (1992) adjusted to HCFA 1998 10-year projections

4. Figure 4. 47 Million Uninsured in 2005; Increasing Steadily Since 2000 Number of uninsured, in millions 2013 Projected *1999–2003 estimates reflect the results of follow-up verification questions and implementation of Census 2000-based population controls. Note: Projected estimates for 2006–2013 are for nonelderly uninsured based on T. Gilmer andR. Kronick, “It’s the Premiums, Stupid: Projections of the Uninsured Through 2013,” Health Affairs Web Exclusive, Apr. 5, 2005. Source: U.S. Census Bureau, March CPS Surveys 1988 to 2005.

9. The Graying of America 1995 2010 2030 Institute for the Future, Health and Health Care 2010 (2000)

10. Prevalence of Obesity & Diabetes in the U.S. 1990/1991 2000 Obesity No Data < 10% 10%-14% 15%-19% ³ 20% Diabetes No Data < 4% 4%-6% > 6% Mokdad et al., JAMA 286:1195–1200, 2001

11. Hospitalization Rates Are Dropping From 1980 to 2004, US days of inpatient care per thousand plummeted across all age groups: Age Change Under 15 - 40% 15-44 - 60% 45-64 - 63% 65 and over - 50% Source: Agency for Healthcare Research and Quality, 2005 National Healthcare Report

12. Hospitalization rates in primary care 72% Source: Stafford RS, Saglam D, Causino N, Starfield B, Culpepper L, Marder WD, Blumenthal. Trends in adult visits to primary care physicians in the United States. Arch Fam Med. 1999;8:26-32.

13. Preventable admissions vary Hospitalizations for Ambulatory Care Sensitive Conditions Source:The Quality of Medical Care in the United States: A Report on the Medicare Program. The Dartmouth Atlas of Health Care 1999. The Center for the Evaluative Clinical Sciences Dartmouth Medical School

14. New Models

15. New Models of Care • Community Care • health education, advisors, care managers, internet access, minute clinics, urgent care • Primary Care • teams, chronic care models • Hospital/secondary care • hospitalists, direct access • Tertiary Care • hospitalists, discharge to primary care

16. Innovative models • Multi-disciplinary teams in community settings • neighborhood-based clinics • school-based clinics • in-home medical care and case management • Designed and delivered together with community partners • Innovative financing built on partnerships

17. 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

18. 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

19. 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 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

21. The Duke Center for Community Research (DCCR) Moving the Community from Subject to Collaborative Partner • Goal: • Improve the health of the community through: • —Community engagement in research • —Integration of practices into research structure • —Linking communities, practices, researchers • Components: • 1. Community Research Liaison Center • 2. Community Health Research Training Center • 3. Electronic Health Record

23. A New Approach • Understand the needs of your communities • Identify the barriers to receiving care • Test methods of improving access, outcomes, and cost in your practices and communities

25. Some areas admit, some don’t Medical Discharge Rates Source:The Quality of Medical Care in the United States: A Report on the Medicare Program. The Dartmouth Atlas of Health Care 1999. The Center for the Evaluative Clinical Sciences Dartmouth Medical School

27. Regulatory Affairs Project Leaders and the Portal Office Duke Translational Medicine Institute

28. 1. Community Research Liaison Center • The connection between Duke and local communities, practices, and organizations • A virtual library: • For researchers to learn about communities • For community groups to learn about themselves • For practices to identify opportunities for improvement • Outreach and training to assist communities with data and to connect communities with researchers

29. 2. Community Health Research Training Center • Train and prepare researchers to work successfully with communities • Train and prepare learners/trainees to research successfully with communities • Conduct formal regulatory training and testing for community engagement

30. 3. DCCR Electronic Health Record • Covers citizens of Durham County • Captures data for Durham County • Develop analytic techniques using data from the DSR • Dealing with co-variates • Meshing advanced laboratory data with long term outcomes • Produce rapid & measurable improvement of community health status • Can perform rapid turn-around intervention studies (V.J. Dzau 2006)

31. http://communityhealth.mc.duke.edu/education/?/masterhealthsciencehttp://communityhealth.mc.duke.edu/education/?/masterhealthscience