New Models of Primary Care
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New Models of Primary New Models of Primary Care Care J. Lloyd Michener, MD J. Lloyd Michener, MD Professor and Chair Professor and Chair Department of Community and Family Medicine Department of Community and Family Medicine Director, Duke Center for Community Research Director, Duke Center for Community Research
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J. Lloyd Michener, MD Professor and Chair Department of Community and Family Medicine Director, Duke Center for Community Research. New Models of Primary Care. Traditional Model of Care. Primary Care. Hospital. Tertiary Care. Kerr White Health Care Ecology Model. - PowerPoint PPT Presentation
Transcript of New Models of Primary Care
New Models of Primary CareNew Models of Primary Care
J. Lloyd Michener, MDJ. Lloyd Michener, MD
Professor and ChairProfessor and ChairDepartment of Community and Family MedicineDepartment of Community and Family MedicineDirector, Duke Center for Community ResearchDirector, Duke Center for Community Research
Traditional Model of CareTraditional Model of Care
Primary CarePrimary Care
HospitalHospital
TertiaryTertiary CareCare
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Kerr White Health Care Ecology Model Kerr White Health Care Ecology Model Kerr White Health Care Ecology Model Kerr White Health Care Ecology Model
Part IPart ICost: Health Care in the U.S. is in CrisisCost: Health Care in the U.S. is in Crisis
$11,431
$22,482
$44,244
$5,555$2,566$1,059$346$143$80$29
$0
$5,000
$10,000
$15,000
$20,000
$25,000
$30,000
$35,000
$40,000
$45,000
$50,000
1940 1950 1960 1970 1980 1990 2000 2010 2020 2030
Per Capita Personal
Health Spending,
US
$11,431
$22,482
$44,244
$5,555$2,566$1,059$346$143$80$29
$0
$5,000
$10,000
$15,000
$20,000
$25,000
$30,000
$35,000
$40,000
$45,000
$50,000
1940 1950 1960 1970 1980 1990 2000 2010 2020 2030
Per Capita Personal
Health Spending,
US
HCFA (1992) adjusted to HCFA 1998 10-year projectionsHCFA (1992) adjusted to HCFA 1998 10-year projections
Figure 4. 47 Million Uninsured in 2005; Figure 4. 47 Million Uninsured in 2005; Increasing Steadily Since 2000Increasing Steadily Since 2000
Number of uninsured, in millionsNumber of uninsured, in millions
31 33 33 35 3539 40 40 41 42 43 44
40 40 4144
56
474645
0
20
40
60
1987 1990 1993 1996 1999* 2002 2005 2008 2011
31 33 33 35 3539 40 40 41 42 43 44
40 40 4144
56
474645
0
20
40
60
1987 1990 1993 1996 1999* 2002 2005 2008 2011
ProjectedProjected20132013
*1999–2003 estimates reflect the results of follow-up verification questions and implementation of *1999–2003 estimates reflect the results of follow-up verification questions and implementation of Census 2000-based population controls.Census 2000-based population controls.Note: Projected estimates for 2006–2013 are for nonelderly uninsured based on T. Gilmer andNote: 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 R. 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.Web Exclusive, Apr. 5, 2005. Source: U.S. Census Bureau, March CPS Surveys 1988 to 2005.
The Graying of AmericaThe Graying of America
19951995
Institute for the Future, Health and Health Care 2010 (2000)Institute for the Future, Health and Health Care 2010 (2000)
2030203020102010
90+
80-84
70-74
60-64
50-54
40-44
30-34
20-24
10-14
< 10
90+
80-84
70-74
60-64
50-54
40-44
30-34
20-24
10-14
< 10
Males FemalesMales Females
Millions12 8 4 0 4 8 12
Millions12 8 4 0 4 8 12
90+
80-84
70-74
60-64
50-54
40-44
30-34
20-24
10-14
< 10
90+
80-84
70-74
60-64
50-54
40-44
30-34
20-24
10-14
< 10
Males Females
Millions812 4 0 4 8 128
Millions12 4 0 4 8 12
Males Females Males Females
Millions12 8 4 0 4 8 12
Millions12 8 4 0 4 8 12
Males Females
Prevalence of Obesity & Diabetes in the U.S.Prevalence of Obesity & Diabetes in the U.S.
1990/19911990/1991 20002000
Mokdad et al., JAMA 286:1195–1200, 2001Mokdad et al., JAMA 286:1195–1200, 2001
No DataNo Data < 4%< 4% 4%-6%4%-6% > 6%> 6%
No DataNo Data < 10%< 10% 10%-14%10%-14% 15%-19%15%-19% 20%20%
ObesityObesity
DiabetesDiabetes
Hospitalization Rates Are DroppingHospitalization Rates Are Dropping
AgeAge ChangeChange
Under 15Under 15 - 40% - 40%
15-4415-44 - 60% - 60%
45-6445-64 - 63% - 63%
65 and over65 and over - 50%- 50%
From 1980 to 2004, US days of inpatient care per From 1980 to 2004, US days of inpatient care per thousand plummeted across all age groups:thousand plummeted across all age groups:
Source: Agency for Healthcare Research and Quality, 2005 National Healthcare ReportSource: Agency for Healthcare Research and Quality, 2005 National Healthcare Report
Hospitalization rates in primary careHospitalization rates in primary care
Source: Stafford RS, Saglam D, Causino N, Starfield B, Culpepper L, Marder WD, 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. Blumenthal. Trends in adult visits to primary care physicians in the United States. Arch Fam Med. 1999;8:26-32.Arch Fam Med. 1999;8:26-32.
72%72%
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
1.8
1978 1979 1980 1981 1985 1989 1990 1991 1992 1993 1994
Admitted
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
1.8
1978 1979 1980 1981 1985 1989 1990 1991 1992 1993 1994
Admitted
Source:The Quality of Medical Care in the United States: A Report on the Medicare 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 Program. The Dartmouth Atlas of Health Care 1999. The Center for the Evaluative Clinical Sciences Dartmouth Medical SchoolClinical Sciences Dartmouth Medical School
Hospitalizations for Ambulatory Care Sensitive ConditionsHospitalizations for Ambulatory Care Sensitive Conditions
Preventable admissions varyPreventable admissions vary
New ModelsNew Models
New Models of CareNew Models of Care
Hospital/secondary careHospital/secondary care• hospitalists, direct accesshospitalists, direct access
Tertiary CareTertiary Care• hospitalists, discharge to hospitalists, discharge to primary care primary care
Community CareCommunity Care• health education, advisors, care health education, advisors, care managers, internet access, minute managers, internet access, minute clinics, urgent care clinics, urgent care
Primary CarePrimary Care• teams, chronic care modelsteams, chronic care models
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Innovative models Innovative models
Multi-disciplinary teams in community settingsMulti-disciplinary teams in community settings
neighborhood-based clinicsneighborhood-based clinics
school-based clinicsschool-based clinics
in-home medical care and case managementin-home medical care and case management
Designed and delivered together with Designed and delivered together with community partnerscommunity partners
Innovative financing built on partnershipsInnovative financing built on partnerships
Walltown and Lyon Park ClinicsWalltown and Lyon Park Clinics
Duke-Durham Neighborhood Partnership:Duke-Durham Neighborhood Partnership:
Neighborhoods ask for access to careNeighborhoods ask for access to care
Population: African-American, new Latino Population: African-American, new Latino population, low-income, transient, population, low-income, transient, uninsureduninsured
Health characteristics: high ED use; inconsistent primary care, Health characteristics: high ED use; inconsistent primary care, high risk health behaviors; substance abuse; depression/anxietyhigh risk health behaviors; substance abuse; depression/anxiety
Partners: Partners: Calvary Baptist MinistriesCalvary Baptist MinistriesWalltown Neighborhood AssociationWalltown Neighborhood AssociationPAC-2PAC-2PAC-3 PAC-3 Lincoln Community Health CenterLincoln Community Health CenterPlanned Parenthood of Central NCPlanned Parenthood of Central NC
Community and Family Life and Community and Family Life and Recreation Center of the West End, IncRecreation Center of the West End, IncSelf-Help, IncSelf-Help, IncDuke Community Affairs Duke Community Affairs Duke Community RelationsDuke Community RelationsDUHDUHCFMCFM
Neighborhood ClinicsNeighborhood Clinics
Keep costs low, easy access, locating clinics in Keep costs low, easy access, locating clinics in
neighborhood settings, NP/PAs as providersneighborhood settings, NP/PAs as providers Duke Endowment, Duke University, Duke Duke Endowment, Duke University, Duke
HospitalHospital >10,000 visits projected for >10,000 visits projected for
FY07 FY07 70% of visits are return 70% of visits are return
visits (continuity)visits (continuity) 37% of patients surveyed 37% of patients surveyed
would have gone to EDwould have gone to ED High patient satisfaction – 4.7/5.0High patient satisfaction – 4.7/5.0
Just for Us: Caring for Durham’s Older Adults in Just for Us: Caring for Durham’s Older Adults in Public and Subsidized HousingPublic and Subsidized Housing
300 home-bound seniors and disabled adults in 300 home-bound seniors and disabled adults in Durham senior low-income public housing, Durham senior low-income public housing, average age, 71, mostly women, African-average age, 71, mostly women, African-American, <$7K annual income, care American, <$7K annual income, care fragmentedfragmented
Multiple chronic diseases, average 5 rxns, 44% Multiple chronic diseases, average 5 rxns, 44% also have mental conditionsalso have mental conditions
Care delivered by NP/PA, SW, OT, PT, RD in Care delivered by NP/PA, SW, OT, PT, RD in homehome
Durham County Health DepartmentDurham County Health DepartmentDurham County Department of Durham County Department of Social Services Social ServicesDuke CFM, SON, DUH, DRH, Center forDuke CFM, SON, DUH, DRH, Center for Aging, Psychiatry Aging, Psychiatry
Partners:Partners: City of Durham, Housing AuthorityCity of Durham, Housing AuthorityLincoln Community Health CenterLincoln Community Health CenterDurham Council on SeniorsDurham Council on SeniorsDuke Center on AgingDuke Center on AgingArea Mental Health AgencyArea Mental Health Agency
The Duke Center for Community Research The Duke Center for Community Research (DCCR)(DCCR)
Moving the Community from Subject to Collaborative PartnerMoving the Community from Subject to Collaborative Partner
Goal:Goal:
Improve the health of the community through:Improve the health of the community through:
——Community engagement in researchCommunity engagement in research
——Integration of practices into research structureIntegration of practices into research structure
——Linking communities, practices, researchersLinking communities, practices, researchers
Components:Components:
1.1. Community Research Liaison Center Community Research Liaison Center
2.2. Community Health Research Training Center Community Health Research Training Center
3.3. Electronic Health Record Electronic Health Record
A New Approach A New Approach
Understand the needs of your communitiesUnderstand the needs of your communities
Identify the barriers to receiving careIdentify the barriers to receiving care
Test methods of improving access, outcomes, Test methods of improving access, outcomes, and cost in your practices and communitiesand cost in your practices and communities
Some areas admit, some don’t Some areas admit, some don’t Medical Discharge RatesMedical Discharge Rates
Source:The Quality of Medical Care in the United States: A Report on the Medicare 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 Program. The Dartmouth Atlas of Health Care 1999. The Center for the Evaluative Clinical Sciences Dartmouth Medical SchoolClinical Sciences Dartmouth Medical School
Duke Translational Medicine InstituteDuke Translational Medicine InstituteDTMI Faculty Leadership
DTMI Administration
DCCRDCRIDTRI
Oddone (K30), Bastian (T32), Hamilton (K12)
McKinney, Burks, McHutchison, Turner
Cuffe, McKinney, Szczech
St. Geme, Li, Benjamin
Cooke-Deegan, Beskow
George
Pietrobon, Krishnan, Ahmad, Cuttechia
Ginsburg, Weinhold, Kurtzberg, Guilak, Charles, Dewhirst, Toone, Hauser
Gilliss
Sullenger Harrington, Schulman, Peterson, McHutchison
Michener, Yaggy,Gilliss, Miranda
DTMI Administration
DCCRDCRIDTRI
Oddone (K30), Bastian (T32), Hamilton (K12)
McKinney, Burks, McHutchison, Turner
Cuffe, McKinney, Szczech
St. Geme, Li, Benjamin
Cooke-Deegan, Beskow
George
Pietrobon, Krishnan, Ahmad, Cuttechia
Ginsburg, Weinhold, Kurtzberg, Guilak, Charles, Dewhirst, Toone, Hauser
Gilliss
Sullenger Harrington, Schulman, Peterson, McHutchison
Michener, Yaggy,Gilliss, Miranda
DTMI Administration
DCCRDCRIDTRI
Education and Training
DCRU
Duke as a Site
Pediatrics
Ethics
Biostatistics
Biomedical Informatics
Core Laboratories
Nursing
New molecule
Preclinical dev.
First-in-human
Phase II/III
Application in the communityNew molecule
Preclinical dev.
First-in-human
Phase II/III
Application in the community
DTMI Organizational Structure DTMI Faculty Leadership
DTMI Administration
DCCRDCRIDTRI
Oddone (K30), Bastian (T32), Hamilton (K12)
McKinney, Burks, McHutchison, Turner
Cuffe, McKinney, Szczech
St. Geme, Li, Benjamin
Cooke-Deegan, Beskow
George
Pietrobon, Krishnan, Ahmad, Cuttechia
Ginsburg, Weinhold, Kurtzberg, Guilak, Charles, Dewhirst, Toone, Hauser
Gilliss
Sullenger Harrington, Schulman, Peterson, McHutchison
Michener, Yaggy,Gilliss, Miranda
DTMI Administration
DCCRDCRIDTRI
Oddone (K30), Bastian (T32), Hamilton (K12)
McKinney, Burks, McHutchison, Turner
Cuffe, McKinney, Szczech
St. Geme, Li, Benjamin
Cooke-Deegan, Beskow
George
Pietrobon, Krishnan, Ahmad, Cuttechia
Ginsburg, Weinhold, Kurtzberg, Guilak, Charles, Dewhirst, Toone, Hauser
Gilliss
Sullenger Harrington, Schulman, Peterson, McHutchison
Michener, Yaggy,Gilliss, Miranda
DTMI Administration
DCCRDCRIDTRI
Education and Training
DCRU
Duke as a Site
Pediatrics
Ethics
Biostatistics
Biomedical Informatics
Core Laboratories
Nursing
New molecule
Preclinical dev.
First-in-human
Phase II/III
Application in the communityNew molecule
Preclinical dev.
First-in-human
Phase II/III
Application in the community
DTMI Organizational Structure
Regulatory Affairs
Project Leaders and the Portal Office
1. Community Research Liaison Center1. Community Research Liaison Center
The connection between Duke and local The connection between Duke and local communities, practices, and organizations communities, practices, and organizations
A virtual library:A virtual library:— For researchers to learn about communitiesFor researchers to learn about communities— For community groups to learn about themselves For community groups to learn about themselves — For practices to identify opportunities for For practices to identify opportunities for
improvementimprovement
Outreach and training to assist communities with Outreach and training to assist communities with data and to connect communities with researchersdata and to connect communities with researchers
2. Community Health Research Training Center2. Community Health Research Training Center
Train and prepare researchers to work Train and prepare researchers to work successfully with communitiessuccessfully with communities
Train and prepare learners/trainees to research Train and prepare learners/trainees to research successfully with communitiessuccessfully with communities
Conduct formal regulatory training and testing for Conduct formal regulatory training and testing for community engagement community engagement
3. DCCR Electronic Health Record3. DCCR Electronic Health Record
(V.J. Dzau 2006)
Covers citizens of Durham CountyCovers citizens of Durham County
Captures data for Durham CountyCaptures data for Durham County
Develop analytic techniques using data from the Develop analytic techniques using data from the DSRDSR
Dealing with co-variatesDealing with co-variates
Meshing advanced laboratory data with long term Meshing advanced laboratory data with long term outcomesoutcomes
Produce rapid & measurable improvement of Produce rapid & measurable improvement of community health statuscommunity health status
Can perform rapid turn-around intervention studiesCan perform rapid turn-around intervention studies
http://communityhealth.mc.duke.edu/education/?/masterhealthsciencehttp://communityhealth.mc.duke.edu/education/?/masterhealthscience
