Community Collaboration To Improve Care And Reduce Health Disparities

PRACTICE: Durham Community Health Network in Durham, North Carolina, and its local and state partner institutions.

WHO AND WHERE: Durham Community Health Network, a public-private partnership providing care management for Durham County residents enrolled in Medicaid or the Children’s Health Insurance Program (CHIP); leaders and faculty from Duke University’s Department of Community and Family Medicine and School of Nursing; the Durham County Health and Social Services Departments; and area hospitals and health centers.

CORE INNOVATIONS: With state funding, care managers are assigned to work individually with patients (and their families) enrolled in Medicaid or CHIP who have chronic diseases. The goals are to reduce barriers to care and improve compliance with treatment. A shared data system issues electronic alerts to care managers when patients visit emergency departments or fail to refill maintenance medications.

KEY RESULTS: A data system captures emergency room visits, unfilled prescriptions, and preventive screenings and issues alerts to care managers. Community-placed kiosks link patients with contextually relevant health information.

CHALLENGES: Effective collaboration requires sharing of funds, information, and decision making. Primary care providers require electronic access to relevant patient data and quality-improvement information. Future clinicians, researchers, and administrators all must be educated in how to achieve community engagement: