Durham Health Innovations:City of Medicine, Community of Health

Michelle J. Lyn, MBA, MHAAssistant ProfessorChief, Division of Community HealthDepartment of Community and Family MedicineAssociate Director, Duke Center for Community Research

Our Context: A History of Collaboration and an Opportunity to Lead…

Duke and Durham Collaboration: A Few Examples…

Community clinics

School-based clinics

Home care for elderly and/or disabled

Care management teams

Specialty Care Access

What we must address… Access, Cost, Quality

What we know….— Most illness related to health behaviors— Disease burden and practice patterns vary

What we believe….Everyone deserves access to simple, proven measures to reduce the risk of dying or losing function.

It is time to rethink the work, redesign the system…

An Opportunity to Lead…

Our Support

Clinical and Translational Science Awards (CTSA) of the National Institutes of Health (NIH)

Duke Medicine

Duke Translational Medicine Institute

Duke Center for Community Research

Durham Health Innovations

The Fundamental Question…

What does it take to move the health indicators for our ENTIRE community?

Co-chairs: Rob Califf, MD, Director, DTMI and Vice Chancellor for Clinical Research, Duke MedicineGayle B. Harris, MPH, Director, Durham County Health Department

MaryAnn Black, MSW, LCSW, Associate Vice President, Office of Community Relations, DUHS

Jackie Brown, Community Advocate

William Fulkerson, MD, Senior Vice President, Clinical Affairs, DUHS

Catherine L. Gilliss, DNSc, RN, FAAN, Dean, Duke University School of Nursing and Vice Chancellor for Nursing Affairs

Ellen Holliman, Director, The Durham Center

J. Lloyd Michener, MD, Chairman, Department of Community & Family Medicine and Director, Duke Center for Community Research

Marie Lynn Miranda, PhD, Director, Children’s Environmental Health Initiative, Duke University Nicholas School of the Environment

Earl Phillips, Assistant Director, Community Engagement, City of Durham

Gerri Robinson, Director, Durham County Department of Social Services

Pilar Rocha-Goldberg, Executive Director, El Centro Hispano

Oversight Committee

Requirements:

Planning Grants

An Interdisciplinary Duke-Durham Team

Relevant Health Issue

Engage Population Most Affected/Most At-Risk

Alternative model of service/care

Institutional Resources in Planning Activities

Financial Model

Evaluation Plan

Dissemination Plan

Stage 1 by the numbers…

22 Duke-Durham teams submitted Stage I Brief Proposals

413 team members –

237 representing Duke and

176 community partners (representing 90 community agencies/organizations and businesses)

19 Duke-Durham teams moved to Stage II

Stage II applications required teams…

Select co-team leaders from Duke and the community

Identify a project manager

Propose, describe, and present evidence for an innovative model of care (i.e., changes in the structure or function of a service, system, or care delivery setting).

Detail how community partnerships would be central to the planning process

Project Areas

Adolescent Health

Asthma and Chronic Obstructive Pulmonary Disease (COPD)

Cancer

Cardiovascular Disease

Diabetes

HIV/STD/Hepatitis

Maternal Health

Obesity

Pain Management and Substance Abuse

Seniors Health

Adolescent Health

Adolescent Health Initiative (AHI)

Team Co-Leads: Kristin Ito, MD, MPH, Duke Department of Pediatrics

Nancy Kent, LCSW, The Durham Center

C. Nicole Swiner, MD, UNC Family Medicine

Yvonne Wasilewski, PhD, MPH, Center for Child and Family Policy

Project Managers:

May Alexander & Wendy Tonker, How’s that working?

Asthma and COPD

Innovative Approaches to Better Detect and Treat Asthma and Chronic Obstructive Pulmonary Disease in Durham (Breathe Easy Team)

Team Co-Leads:

Monica Kraft, M.D., Duke Asthma, Allergy and Airway Center

Betty Masten, M.D., Lincoln Community Health Center

Project Manager:

Rhonda Webb, M.S., Duke Asthma, Allergy and Airway Center

A Partnership for Community Wellness in Durham, NC

Cancer Prevention and Early Detection

Team Co-Leads:

Victoria Seewaldt, M.D., Duke Pharmacology and Cancer Biology, Cancer Control and Prevention

Sharon Elliot Bynum, RN, BSN, MA, Ph.D., Healing with CAARE, Inc.

Anne Ford, M.D., Duke Department of OB/Gyn

Gustavo Montana, M.D. Duke Radiation Oncology

Vladirir Mouraviev, M.D., Ph.D., Duke Department of Surgery

Marva Price, DrPH, RN, FAAN, Duke University School of Nursing

Stephanie Robertson, Duke University Comprehensive Cancer Center

Valarie Worthy, R.N., Sister Network, Durham/Triangle Chapter

Project Manager:

Jeff Birnbaum, B.S.E., Duke Department of Medical Oncology

Cardiovascular Disease

Vascular Intervention Project (VIP)

Team Co-Leads:

Kevin L. Thomas, M.D., FACC, FAAC, Duke Division of Cardiovascular Disease/Duke Clinical Research Institute

Sharon Elliott-Bynum, RN, MSN, Ph.D., Healing with CAARE Inc., Jeanne Lucas Education and Wellness Center

Project Manager:

Kristin Dossary, Duke Clinical Research Institute

Diabetes

Partnership IMPACTS Diabetes Outcomes

Team Co-Leads:

Gloria Trujillo, M.D., Duke Department of Community and Family Medicine

Kathryn Trotter, MSN, CNM, FNP, Duke University School of Nursing

Michele Easterling, MPH, RD, Durham County Health Department

Nichole Weedon, MSW, P-LCSW, Durham County Dept. of Social Services

Project Manager:

Rachel Kuliani, MPH, Durham Health Innovations

HIV, STD and Hepatitis Prevention and Care

Prevention and Treatment of HIV,STDs, and Hepatitis in Durham County

Team Co-Leads:

John Bartlett, MD, Duke Global Health Institute / Infectious Disease Clinic

Arlene Sena, MD, MPH, Durham County Health Department, UNC-CH Division of Infectious Diseases

Project Managers:

Mary DeCoster, MPH, Durham County Health Department

Marc Kolman, MSPH, Piedmont Health Care Consortium

Maternal and Child HealthThe Maternal and Child Health Intervention Group (MCH Group)

Team Co-Leads:

Monique Chireau, M.D., MPH, Duke Department of Obstetrics and Gynecology

Tamera Coyne-Beasley, MD, MPH, Community Health Coalition / UNC-CH Dept. of Pediatrics and Internal Medicine

Sue McLaurin, M.Ed., PT, Community Health Coalition

Maria Small, MD, MPH, Duke Department of Obstetrics and Gynecology

Project Managers:

Tammy Bishop, RNC, MSN, Duke Department of Obstetrics and Gynecology

Lottie Barnes, MPH, CHES, Community Health Coalition

Obesity

Achieving Healthy Bodies for a Lifetime (AHL)

Team Co-Leads:

David Reese, MBA, Chief Operating Officer, Inter-Faith Food Shuttle

William Yancey, Jr. MD, MHS, Duke Department of Medicine

Project Manager:

Jennifer McDuffie, PhD, General Internal Medicine, Durham VAMC

Pain Management and Substance AbuseRethinking Pain: Collaborative Approaches to Address the

Relationship of Pain, Substance Abuse, and Psychiatric Illness

Team Co-Leads:

Fred Johnson, MBA, Duke Division of Community Health

Cathleen Melton, MD, Lincoln Community Health Center

Project Manager:

Sarah Weaver, MPH, Duke Division of Community Health

SeniorsSeniors Healthy in Place "HIP Seniors"

Team Co-Leads:

Robin Ali, MD, PharmD, Duke Dept. of Community and Family Medicine

Brenda Jamerson, PharmD, Duke Psychiatry and Behavioral Sciences, Campbell University School of Pharmacy

Ellie McConnell, RN, PhD, GCNS, BC, Duke School of Nursing

Joan Pellettier, Triangle J Area Agency on Aging

Gina Upchurch, RPh, MPH, Senior PharmAssist

Project Manager:

Carolyn Kroll, MA, CK Kroll & Associates. Inc.

Technical Assistance CoresCommunity Engagement

Data and Analysis Plan Development

Co-Chairs:Michelle Lyn

Earl Phillips (City of Durham Housing and Development)

Co-Chairs:Marie Lynn Miranda

Becky Freeman (Durham County Health Department)

Co-Chairs: Krishna Udayakumar

Casey Steinbacher (Durham County Chamber of Commerce)

Data confidentiality issues

Analysis

Modeling

engagement

Facilitating

conversations

Connecting to other

teams

DSR and other linked data

Business data

Data from teams

Geospatial mapping

Alternative models

of care

Business plan

development

Finding Common Ground

Elements of a Connected Care Model

1. Population Analysis and Risk Stratification

2. Metrics and Accountability

3. Care Management/Care Coordination

4. Communication

Common Elements Across Teams

1. Population Analysis and Risk Stratification

People with or at high risk for health problems

Risk stratification that accounts for health status, socio-economic and environmental factors

Assess neighborhood- and community-wide health status and identify opportunities for health improvement

Common Elements Across Teams

2. Metrics and Accountability

Collaboratively identify key measures to:

- determine extent of the health problems

- track progress

- inform decision-making and resource allocation

Common Elements Across Teams

3. Care Management / Care Coordination

Community health advocates

Optimal use of all providers including specialist and primary care physicians

Care closer to people’s homes and neighborhoods

Tight coordination of clinical services, home health, hospice, pharmacists, respiratory therapy, etc.

Opportunities for group visits, home visits, and use of internet technology for health care strategies

Common Elements Across Teams4.Communication

Engage community input throughout the entire process

Leverage information technology and informatics capabilities to facilitate improved communication

— across community and providers — improve decision-making (via availability of

critical information, decision support tools, risk-stratification tools)

— information & referral

Care designed with communities and providers that optimizes the use of non-traditional and traditional providers so that it is:

—Close

To home, neighborhood, school, workplace…

—Connected

Individuals to health providers

Health providers to each other

—Accountable

Measurable performance with consequences

It is a fundamental redesign, not a substitution model, not a “lesser” model

Combining team efforts results in…

Challenges and Lessons Learned

Each step of the way

Through every process

In each relational group

Next Steps…

What we have:

A shared understanding that we ALL have a role to play in improving the health of our community

What we need:

An open commitment by ALL of us that improved health outcomes is a shared goal and that ALL of us are willing to be held accountable for our work toward that goal

Next Steps…

What we must do:– Continue to focus on engagement – Achieve consensus on our expected outcomes

and how we will measure them– Recognize this is not and should never be a

“one intervention fits all” approach– Set realistic expectations of time – this is NOT

a short-term effort - it will require phases of implementation

– Demonstrate the positive economic impact of health-related activities

Our First Steps…– Finish synthesizing the work of the teams

and incorporate YOUR input– Expand the DHI Oversight Committee – Provide project management, quantitative

support, and grant writing support to the teams

– Appoint an Informatics and Information Technology Committee

– Appoint Implementation Team to operationalize strategies and ensure coordination of effort across the work of the teams

Poster Session: A Discussion with DHI Participants