Duke Med ‘doing the right thing’

The raucous debate over health care legislation in 2009 brought issues of medical care and cost management to the national forefront. In Durham, Duke’s Division of Community Health has addressed the issues at a local level by crafting its own health care delivery system within the community.

Since 2003, Duke’s Division of Community Health has partnered with the Lincoln Community Health Center in Durham in attempt to provide better, more informed primary health care by reaching out to the recipient communities. In doing so, DCH’s aim is to foster greater health in the community, which could reduce the need for expensive, uninsured emergency room visits.

“The premise, really, is thinking about health care differently,” said DCH Division Chief Michelle Lyn. “What makes sense for people in the context of their lives—where they live, where they work, where they play? That can look very different from what we may think of in a traditional health care facility.”

LCHC has provided Durham residents with a wide range of low-cost medical care since 1971. It is a Federally Qualified Health Center, which means it meets certain criteria to receive enhanced Medicare and Medicaid reimbursement. Requirements include providing for an under-served population and offering a sliding fee scale based on income—for example, at the clinics, costs of visits by uninsured patients in the lowest income bracket are capped at $20. Through the partnership, Duke’s resources have made it possible to expand these services beyond the geographical scope of LCHC’s facilities.

Duke, Durham and the Duke Endowment have contributed funds to establish three new clinics since 2003: Lyon Park Clinic, Walltown Neighborhood Clinic and Holton Wellness Center. Lincoln pays a contract fee, but Duke still contributes to operational costs and the medical providers are Duke medical personnel.

Lyn described the creation of the new clinics as the result of a patient-centric healthcare philosophy.

“When we put the clinics together, we did lots of interviews, talking with people about what makes sense in terms of care and care delivery, the types of services, the way the clinics would be structured,” she said. “We built the clinics around those responses.”

“We wanted to locate the clinic right in the middle of Walltown so that it’s convenient [and] it serves the people who need it the most,” Williams said.

Physician Assistant Kaitlyn Granda, the first clinician to work at Walltown on its creation in 2005, said the familiarity of a community-based health clinic is beneficial for patients.

“[Patients] come in and we know them by name and know their situation,” Granda said. “It feels much more intimate and homey to them than a big hospital. They’re seeing us each time they come in and that’s comforting to them and to us.”

Reinventing the house call

Duke’s DCH provides comprehensive services to the Durham community, such as sponsoring health clinics in four of Durham’s public schools as well as running a program, titled “Just for Us,” which targets the needs of senior citizens who live independently but still require routine health care.

“What we’ve done with [the Just for Us] program is, quite frankly, reinvented the house call,” Lyn explained. “[Medical teams] put all their equipment in [rolling suitcases]... and we actually deliver care within patients’ apartments.”

Lyn and Fred Johnson, deputy director of community health and director of clinical services, both have masters in business administration degrees, not medical degrees. Johnson explained that their backgrounds provide a unique advantage for leading DCH and emphasize an open-office culture.

“We have a different appreciation for how organizations work,” he said. “We get [doctors] to step back and paint a broad picture.... We tend to ask more question than give solutions and get [the medical staff] to respond.”

“Right care”

Dr. Victor Dzau, chancellor for health affairs and president and CEO of the Duke University Health System, noted that the clinics have led to a more effective use of Duke Hospital emergency rooms. The clinics deal with medical issues earlier, while community health programs promote healthy living and wellness in the community, he explained, adding that the programs provide a buffer against uninsured hospital usage.

In fiscal year 2007-2008, Duke had to shell out $45 million in care for patients who could not pay hospital fees as well as $50.5 million for the costs that Medicaid did not fully reimburse, according to a DUHS report. The report also cited additional expenses of $57 million in “unreimbursed costs of treating Medicare patients” and $31 million in “unrecoverable patient debt.”

Compared to losing $183.5 million, the $7.5 million that Duke invests annually in the LCHC partnership may prove cost-effective if it substantially reduces those hospital expenses. According to a report by the Gerontological Society of America, during the 2003-2004 fiscal year—the first full fiscal year that the Just for Us program was implemented—Duke Hospital expenditures for patients qualifying for Just for Us and Medicaid decreased by 49 percent in costs linked to ambulance-related emergencies, 41 percent in costs of emergency room visits from patients in the county and 68 percent in inpatient hospital costs.

Dzau described the motivations for community health involvement as primarily about “doing the right thing.” He noted, however, that the Duke community-based health approach additionally puts DUHS in a favorable position to adapt to impending changes in the national health care field, such as cutting back on redundancies and expenses like excessive testing.

“[What DCH has is] a team of people taking care of the patient, not just a physician who’s just too busy in a shortage anyway,” Dzau said. “We have not only the clinics and the community activities, but also right care at the right time in the right place.”

Samantha Brooks contributed reporting