Health care program brings back house calls

HealthA model health care system operates behind Marietta Moore’s apartment door in a subsidized housing complex in Durham.

Moore, 89, has diabetes, high blood pressure and had suffered a stroke. A widow, she has limited family support aside from her nearby daughter.

Getting the health care she needs would take a near-constant effort of scheduling regular checkups at her doctor’s office, keeping her 17 prescriptions filled and compliant, and arranging the public transportation to get from one place to the next. All on a fixed income.

Instead, Moore’s health care team comes to her.

Moore is one of about 350 older people in Durham enrolled in a Duke University-led program called Just for Us that is designed to recreate the way medicine is practiced in communities. People who are frail, sick, impoverished or socially isolated are treated before their ailments land them in the hospital. That can lower costs, which are a key hurdle that any health reform plan must overcome.

A year after the Duke program’s launch in 2002, it cut 49 percent of Medicaid dollars spent on ambulance rides for its patients, 41 percent spent on emergency room visits and 68 percent spent on hospital admissions.

The Durham program provides a glimpse into a system of care that many say should be expanded and adopted nationwide.

“It’s a redesign,” said Dr. J. Lloyd Michener, chairman of Duke’s Department of Community and Family Medicine. “It’s not about spending more money, but taking the money we’re currently spending and partnering more effectively with the community.”

The program is just one that Duke participates in with other local groups, including Durham County’s health department, clinics, doctors’ offices, mental health services and the local housing authority.

A decade ago, the groups came together to figure out how they could help residents improve their health and reduce expensive hospital visits for many largely preventable problems. They began an asthma program for youngsters, targeted new immigrants and transients, focused on diabetes.

They decided to start the Just for Us project for older adults, an especially vulnerable group with high medical expenses and a lot of unmet needs. But improving care for these patients took an investment to build the traveling team of doctors, physician assistants, nurse practitioners, nutritionists, social workers and others who provide care to patients where they live.

Dr. Robin C. Ali, the program’s medical director, said the home visits are the key to the program’s success, and an invaluable diagnostic tool.

Unlike a clinical visit to a doctor’s office, a home visit seems more like a social call. Patients open up, explain how they ration pills when money gets tight, or fear visits from an alcoholic relative who may be abusive.

“You see where people live, you understand what’s going on with them,” Ali said. She said she frequently checks patients’ refrigerators to be sure they have food, or she notes when a cluttered room presents a falling hazard.

Moore, who moved to Durham six years ago to be closer to her daughter, says she looks forward to her care team’s visits every six weeks.

“I wish they came more often,” she says.

Such successes have spurred a more ambitious approach. Earlier this year, the Duke-Durham partnership announced a larger effort to tackle 10 chronic illnesses using some of the same community-based strategies to keep people healthy and out of hospitals.

The Durham Health Innovations project, funded by the National Institutes of Health, aims to improve outcomes for cardiovascular diseases. cancer, asthma, HIV/AIDS, diabetes and others. Care will be centered at a doctor’s office, but a vast network of providers will be tapped throughout the community.

“This was a pretty bold initiative for groups to come together to say we’re going to change the health status of the community,” said Gayle Harris, Durham County’s public health director. “We’re learning lessons as we go. All the answers aren’t there, but I think it is a model worth looking at.”

Projects are in the planning stage and may begin rolling out next year, said Michener at Duke.

Michener said the community partnership model provides a blueprint for saving money. He cites figures from the Dartmouth Atlas of Health Care, which tracks Medicare spending.

In 2006, hospitals in Durham spent $7,202 on each Medicare enrollee, compared to hospitals in Raleigh that spent $8,051.

But Michener said the discussion should not just focus on saving money. Instead, he said, it should ask how to spend it more wisely.

“It’s really a different way of viewing the world,” he said.

(c) 2009, The News & Observer (Raleigh, N.C.). Source: McClatchy-Tribune Information Services.