By Ratna Swaminathan
In 1995, Susan D. Yaggy, MPA, asked J. Lloyd Michener, M.D., a question he’d been working on for years: Why was the department named “Community and Family Medicine” when there was a Division of Family Medicine but no services focused on community? Longstanding health issues of communities in Durham and its vicinity drove the conversation further.
Yaggy’s question was pertinent. Both the U.S. Centers for Disease and Control and Prevention and the N.C. Department of Health and Human Services had extensively documented wide and longstanding gaps in morbidity and mortality in North Carolina, including the Durham area. Low-income and uninsured patients; African-American patients; and those who faced barriers due to language, literacy, cultural norms and lack of transportation had poorer health status and lower life expectancy. Michener, chair of the Department of Community and Family Medicine at the Duke University School of Medicine, hoped for an initiative at Duke that would serve as a dedicated arm to the underserved populations of the Durham community.
In the ensuing months, Michener joined Yaggy, who served on several local, state and national boards and commissions in public and community health, to begin reaching out to potential partners in Durham to collaborate on improving the health of the community.
A precedent to community engagement did, in fact, exist at Duke. The Department of Community Health Sciences (later renamed the Department of Community and Family Medicine) was formed in July 1966 under the leadership of E. Harvey Estes, Jr., M.D.
In the late 1960s, Estes hired a South African-trained physician, Eva Salber, M.D., to head a community health education program in the department. Estes says her assignment was to get the department involved with the problem of a widely dispersed rural population of underserved patients in northern Durham County.
“She did a house-by-house survey of every dwelling in the northern part of the county, collecting information about these people and their health needs,” Estes recalls. The effectiveness of the division, however, had ebbed and flowed with time, and ultimately the division was shut down in 1991.
After becoming chair in 1995, Michener, who had trained under Salber, felt that the Department of Community and Family Medicine needed to build upon the foundation that she had established. Michener sought to create both an academic and a clinical unit serving the diverse needs of the local community. He recognized that an institutional response by Duke was necessary, especially due to the increased demand for primary care services for low-income and underserved patients. Lincoln Community Health Center (LCHC), a nonprofit federally supported community health center, served this population, but the large number of patients and their complex needs created challenges.
Based on Salber’s platform, a small unit and a precursor to the division, the Office of Primary Care Initiatives, formed within the chair’s office in 1996.
Soon Yaggy and Michener, along with Mary Champagne, dean of nursing, and Duncan Yaggy, associate vice president of Duke University Health System, explored an ambitious collaborative endeavor with LCHC, the then-Durham Regional Hospital and the Durham County Health Department. After what Susan Yaggy describes as “six months of uncomfortable meetings,” the partners launched a community-based and family-centered asthma project with a spotlight on low-income Durham residents.
“We were certainly not the first to see those needs, but were, I believe, the first organized unit devoted to dismantling barriers, helping low-income patients manage their chronic disease and operate clinical services, not just at Duke, but in the community, at home, and at school,” Yaggy says.
Duke, LCHC, Durham Regional Hospital and Durham County Health Department then partnered to set up a school-based primary-care clinic at Watts Elementary School. Current division chief Michelle J. Lyn, MBA, MHA, who at the time worked with Durham Public Schools, later brought a request and funding for another school-based clinic at Southern High School, and, along with Champagne and Yaggy, created the Southern High School Wellness Center in 1996.
Significantly, in 1997, the state awarded the team a contract for a new pilot Medicaid care management program. In July 1998, the partners started managing care jointly for the 10,500 Medicaid patients of Duke Pediatrics, Duke Family Medicine and LCHC, managing patients’ needs at home and in the community. Duke’s new community health unit and its local partners were now running 15 community-based programs, many also in collaboration with the Duke University School of Nursing.
The impetus to improve health care for the Durham community skyrocketed when the Division of Community Health became a full-fledged clinical division of Duke University Medical Center on July 1, 1998. Yaggy, who had been the founding director of the North Carolina Center for Child and Family Health and served as acting director of the Division of Public Health and deputy Medicaid director in New Hampshire, was named division chief.
A people-centric approach
The division is unique at Duke. “Unlike traditional units where a faculty member would create a program based on his or her field of interest, our programs were created by talking with patients in their homes or schools or community centers to find out what they needed, then crafting those programs with the partners,” says Yaggy, proudly.
Michener agrees: “Our job is to understand, to serve, and to train. You go out and meet with different groups and try and understand those different needs and how to meet those effectively. You engage them where they live and work. In community engagement, you don’t wait for people to find you, you go and find them.” The community partners are there every step of the way — from formulation and design of all projects, to structuring of their funding, to their execution and evaluation, he explains.
Calling it “good old-fashioned community organizing,” Lyn, who joined the division in 1998 and became its chief in 2008, explains how they gathered health data, analyzed it, and made sense of it by getting to know neighborhoods, talking to community leaders, and interviewing residents in their homes, asking open-ended questions to find out their needs, in their own words.
By 2009, the Division of Community Health, jointly with LCHC, was supporting primary care clinics at Lyon Park, in the Walltown neighborhood and in northeast Durham at the Holton Wellness Center, providing care for a population that largely comprised Medicaid recipients and uninsured patients. More school-based clinics were also launched and services were expanded at the Southern High School clinic.
Always “an entrepreneurial group,” as Michener puts it, the division has sustained its operations on grants, contracts and tuition, with a substantial amount of support coming from the Department of Community and Family Medicine when it began. As the success and value of the programs became apparent, operational support switched to the Duke University Health System, and the state. The division’s research and data analyses have shown how it has saved money for the institution by keeping patients out of the hospital and emergency departments, says Michener.
Eighteen years on, this academic group has gained prominence on the national stage by showcasing how it excels in analyzing population needs, designing interventions, testing them and disseminating knowledge. Though 45 collaborative, community-based clinical, care management, education and research initiatives across seven state counties form quite a track record, the team isn’t resting on its laurels. Michener is pondering another question: how to use the same methods to design more effective strategies to help people with less common illnesses?
Folks in the Division of Community Health are listening and, once again, looking for solutions.
For more information about the Division of Community Health, visit communityhealth.duke.edu.
Ratna Swaminathan is a freelance writer and editor in Durham.
Coming next week: History of the Division of Family Medicine