Just for Us
Since 2001 a unique program has been underway in Durham to connect more low-income, “medically fragile” seniors and disabled adults with in-home health are in an effort to better manage chronic disease and provide services.1
As part of Duke University Medical Center’s Department of Community and Family Medicine, the “Just for Us” program offers a range of health care services to the elderly and disabled adults, the majority of whom reside in Durham’s public housing complexes. Much like the PACE program, individual care is managed by a team of providers, including the patient’s primary-care provider (PCP), as well as a social worker, and nutritionist, all with the goal of keeping the patient in their community, better coordinating their care, and sustaining their independence.
“Initially, the focus of the program was to coordinate care for the patient and follow up on plans made by the primary care provider,” says Dr. Robin Burnette, former medical director of Just for Us. “However, they found that patients were not returning to their PCP regularly. Thus, Just for Us was started to deliver those basic primary-care services.” Just for Us operates through a partnership between multiple agencies, including county-level health departments, the city housing authority, a nationally-recognized research hospital, and a community-health center. The partnership allows the program to execute a multifaceted approach to in-home care for medically frail seniors and better coordinate services to support and maintain their independent living.
Cost of care is mitigated because the concentration of medically frail and low- income seniors in public housing allows for a centralized delivery of services. Likewise, the interdisciplinary approach to care and case management helps to identify and connect elderly and disabled adults to the benefits for which they are eligible. In 2002, at the start of the program, only 28 percent of participants were enrolled in Medicaid, despite the fact that many more were eligible. Physical barriers, such as transportation and long waits, discouraged enrollment. Two years later, due to more efficient and integrated case management, Medicaid enrollment was more than 90 percent for program participants, meaning more financial assistance was available to support care.2
The Just for Us program has shown promising cost rebalancing in expenditures for Medicaid recipients enrolled in the program, such as decreased spending on ambulance usage by participants, fewer emergency department visits, and a significant drop in spending on inpatient hospitalization between fiscal years 2002–03 and 2003–04.85 “Going into the home gives the provider a better idea of the patient’s experience than you are able to achieve in the clinic,” says Dr. Burnette. “In particular, you see a patient’s accessibility, medication related issues, caregivers, food, and cleanliness.”
Todd Brantley is a researcher and writer from Raleigh. Amy Brantley is a medical instructor and physician assistant at Duke Family Medicine Center in Durham.