Since 1998, the department has undertaken a number of "experiments" with different practice types and alternative models of service delivery. The intent of these was to develop practices that met the needs of the surrounding community, and could be financially sustainable.
Suburban multispecialty faculty practice
The first experiment was modest – to join in the academic health center's expansion efforts and establish a suburban family practice in a multi-specialty office (Table 1, column 2). Located in a fast-growing area near a large shopping center, this practice was designed to appeal to the relatively young, commercially insured population living and working nearby. Despite a better payer mix, this practice was financially unsuccessful. High space costs ($55/sq.ft.) combined with lower than expected visits led to substantial losses. This family practice office was closed within 3 years.
Small community clinic
The next experiment sought to provide care to an underserved neighborhood near the university, with high proportions of individuals uninsured or insured through Medicaid (Table 1, column 3). Discussions were opened with a nearby federally qualified community health center (CHC) about operation by the department as a satellite clinic of the CHC, staffed by two physician assistants and a nurse, and supported by a member of the family medicine faculty and a staff assistant. A contract between the CHC and the department allowed the department to hire the personnel and pay for the time of the faculty physician, with the clinical operations billed through the CHC at a per-visit rate, regardless of payer source. The clinic is able to charge patients on the CHC's sliding scale fee, making health care affordable for indigent patients. Space for the clinic was secured within a city-managed neighborhood center, where access for the neighborhood was easy, and overhead costs were low.
The new office, now in operation for close to two years, incorporates many of the aspects of the new model of family practice . The office provides a personal medical home for its target population, 65% of whom are new Latino immigrants. Patients are 74% uninsured, and 19% are covered by Medicaid. The practice provides patient-centered care, eliminates barriers to access, and provides care in the community context. Furthermore, it uses an electronic health record developed at Duke, and focuses on quality and safety. Learners rotate through the clinic on an elective basis, but no learners are based at the site. As shown in Table 1, high volume and low overhead, combined with per-visit CHC reimbursement for both Medicaid and uninsured visits, and electronic records linked to the main information system of the academic health center, allow the small clinic to provide care in a previously underserved – or even unserved – community .
The community clinic has already shown clear evidence of value to the health system: a 2004 survey of clinic patients, with a 96% response rate, revealed that of the patients who came to the clinic as drop-ins (52% of visits), 40% said they would have gone to the emergency room if the clinic were not available. Emergency department diversion for uninsured patients represents a significant cost savings for the health system. As the clinic continues to grow, and establishes its patient panel, improved (though still deficit) operations are forecast for its third year.
A third initiative was the establishment of clinics in 3 elementary public schools and a public high school in Durham. These clinics reach children and adolescents that are rarely seen in the traditional office. Each clinic is operated in donated space within the school with no overhead costs assessed to the department. The high school clinic is staffed by a nurse practitioner (NP) and a full-time nurse; the elementary school clinics are each staffed by a half-time NP and a receptionist whose time is donated by the school district. All clinics are supervised by off-site faculty physicians and all provide limited, elective learner participation. A financial summary of the high school clinic (Table 1, column 4) shows a small operating deficit, primarily related to lower billable visit rates and the absence of the per-visit fee from the CHC to cover indigent students.
The school clinics serve as an alternative source of care than the emergency department. Responding to a 2004 survey, parents of students indicated that they would have taken the child to the emergency department for 8% of the visits, which amounts to 127 emergency department visits averted. In addition, 89% of the elementary school clinic visits and 95% of the high school clinic visits resulted in the child's return to class, rather than being sent home. As a result, the school clinics have been continued, with support from the health system.
Home-based senior care
A three-year-old senior health program places a geriatric nurse practitioner and a physician assistant with geriatric experience in senior public housing sites, with oversight from a senior faculty family physician and support from 2 staff assistants. The program staff includes 3 social workers, contracted through the county social services agency, who provide in-home case management and help enroll patients in Medicaid and other public programs (financial summary from the initial project site is in Table 1, column 5). Residents rotate through the site as part of the community health rotation; it is also the site for care by the community health fellow. Billing is again through the federally qualified community health center, this time with a per-visit rate for Medicaid patients, and a nominal rate for uninsured patients. This is an 'office-free' model of care, now serving 362 low-income, medically fragile seniors in their own homes. The practice has a high level of patient acceptance and can break even at 9 visits per day. After three years of operation, the program is nearing this point.
By lowering the barrier to seeking care, acute conditions may be treated earlier and chronic conditions can be monitored closely, with hospital admissions and nursing home stays avoided. The program has recently expanded to 10 senior housing projects around the county. State Medicaid data for 2003 and 2004 show that, for patients enrolled in this senior program during the most recent two-year period, ambulance costs decreased 49%, emergency room costs decreased 41%, and in-patient hospital costs decreased 68%, while prescription costs, costs to the Community Alternative Plan for the Disabled (CAP-DA), and home health costs increased .
Reforming the traditional practice
Finally, the core teaching family practice was moved out of the faculty practice plan in 2002 and is now operating as a hospital-based facility (Table 1, column 6). The costs of operating the office are now incurred by the hospital, which bills a facility fee for each visit. Professional charges are billed by the practice plan but at a reduced rate, which varies based on the contracts held by the hospital. This shift to a hospital-based facility has had only a minor effect on patient volume and throughput, and produced minimal changes in payer mix. It has, however, constituted a substantial economic shift, with the family practice no longer requiring financial subsidy.
Based on the earlier experiments that used physician assistants and nurse practitioners as providers, team-based care has also been instituted. Faculty physicians are now co-leaders with midlevel providers on teams that include other physicians and midlevel providers, residents, nurses, and nursing assistants. Reception staff, a social worker and a pharmacist support the teams. Expansion of services within the practice is now underway, including the addition of a dietitian, physical therapist, and health educator.