What's Old Is New Again

An innovative community-based program keeps Durham's elderly population healthy while reducing health-care costs

Robin Ali parks her Acura MDX in the Oldham Towers parking lot on an overcast morning in May. Built in 1969, the downtown Durham public-housing high-rise has seen better days. Ali is here for her first stop of the day. She's checking in on eighty-six-year-old Carrie Coates, discharged from Duke Hospital the previous afternoon for treatment of a blood clot in her left leg.

Ali is the medical director of Just For Us, an innovative in-home care program for Durham's elderly, frail, and low-income population. Launched in September 2002, Just For Us is a collaboration among Duke University Health System (DUHS), Lincoln Community Health Center, the Durham Housing Authority, and Durham County's departments of health, housing, and social services. The program emphasizes personalized, preventive, cost-effective care—in effect, updating the old-fashioned notion of house calls with a new paradigm for containing health-care costs. Ali is a geriatrician and pharmacist by training, but as a key member of a team caring for nearly 350 elderly residents, she has to play multiple roles—administrator, psychologist, negotiator, advocate, ally.

A whippet-thin woman in her early forties, Ali manages a network that includes the Just For Us staff—a physician assistant, a nurse practitioner, a social worker/case manager, a nutritionist, and an occupational therapist—and is the liaison between the program and its partner agencies. The two cell phones she carries ring constantly. ("One's my personal phone, but I give both numbers to everyone," she says.)

Wheeling her rolling doctor's bag into one of Oldham Towers' elevators, Ali pushes the sixth-floor button and summarizes Coates' status. "She is sweet as pie, cognitively intact, lives alone," says Ali. Exiting the elevator, Ali makes a beeline for Coates' apartment, at the end of an outdoor breezeway. She knocks firmly on the apartment door.

"Ms. Coates, it's Dr. Ali," she announces. A television set blares in the background. A weak voice calls out, "Coming."

The door opens. Coates, dressed in a shapeless, faded housecoat and slippers, greets Ali with a soft hello and a smile, slowly moving aside to let her enter. The one-room apartment has walls of faded white cinderblock and in its small confines contains a life's worth of family photos, small animal figurines, worn furniture, and artwork with Biblical messages. Ali encourages her to sit down and begins taking out medical equipment—finger pulse, blood-pressure cuff, scale.

"You sounded winded, why is that?" Ali asks. Placing her left hand on Coates' shoulder, she tells her to take deep breaths while listening to her lungs through a stethoscope. During the course of her forty-minute visit, Ali screens Coates' vital signs, reviews the hospital discharge instructions, and questions what Coates has had to eat since getting home. She takes a look in Coates' tiny kitchen, peering in the refrigerator.

"Who is shopping for you?" Ali asks. "Who is making meals for you while you get back on your feet?"

Coates hears the query but doesn't answer.

"Ms. Coates, I know how much you like to be independent, but is it okay if I call and get you some help, just for a little while?" Coates concedes that would be fine. Ali calls to arrange for a home-health aide to assist with meals and light cleaning for two weeks.

When it comes to prescriptions, there is more resistance. The ER physicians who treated Coates' blood clot advised putting her on three new medications, including an anticoagulant.

"My mama lived until she was ninety-three, and she never took any medicines or went to a doctor," says Coates. "I just don't believe I need to take any more medicine."

Ali doesn't miss a beat. "Look, I will make you a deal. You don't have to take these other two right now. We can talk about those later. But you have to take the Coumadin. That clot has to go. It's only for six months, okay? Can you do that?"

"I suppose I can do that," says Coates reluctantly.

"Okay, we have a deal, right? And I can trust you to call me if you need help, right?"

Coates promises to follow Ali's orders.

Just For Us came about when a group of Durham community partners convened to examine how to promote health and maintain independence among Durham's elderly and low-income population. Duke representatives included Susan Yaggy, then-chief of the division of community health, and Evelyn Schmidt '47, M.D. '51, director of the Lincoln Community Health Center (see Duke Magazine, July-August 2008). The program is administered jointly through DUHS and Lincoln.

Encouraging healthy lifestyles and allowing people to remain in their homes makes good common sense. But it also makes good economic sense. "The goal," says Ali, as she drives to her next appointment, "is to keep people out of the hospital and the emergency room." The Just For Us team can identify problems before they become chronic, manage multiple courses of treatment, and make sure that the transition from hospital to home is well managed, including persuading a patient to take essential medications that will keep her from returning to the ER in crisis mode.

The program is funded through a combination of Medicare and Medicaid reimbursements and contributions from DUHS—money already being spent on health care. But at a time of escalating health-care costs and a growing elderly population, the community-based, collaborative design of Just For Us is an effective way of using limited resources for high impact: In its first two years, ambulance transports were down 49 percent, emergency-room visits declined by 41 percent, and hospital admissions were down 68 percent.

Ali pulls up in front of Francis Pierce's house on a quiet residential street off of University Drive. The two women embrace like sisters. Unlike Coates, Pierce enjoys the support of a tight-knit extended family that lives close by. At eighty-one, she still tends her garden and has started practicing yoga three times a week. She has maintained a healthy diet all her life, augmented by herbal supplements and vitamins. ("You can always tell the people who have taken care of themselves," Ali says later. "What you do to your body throughout your life always catches up eventually.")

The visit goes well, although Pierce says she's noticed that her hair is receding, most likely a side effect of one of her prescriptions. Before leaving, Ali asks Pierce to step on the scale. She's lost seven pounds since Ali's last visit. "That's too much," says Ali. "Do you want help with meal prep? Another thing is to get a Carnation Instant Breakfast and mix it in with your soy milk every morning. You have to keep your vitality up."

At the end of the visit, the two women join hands on the living room sofa, bow their heads, and pray for continued strength and healing. It's a ritual they've followed since their first meeting, about a year ago.

As Ali puts her bag back into her car and prepares to head to southwest Durham for her next client visit, she mentions the growing need for more geriatricians, a wider array of social services, and the expansion of programs like Just For Us to address Durham's expanding elderly population.

"I have a relentless passion for caring for older people," Ali says. "This is the change I want to lead." Before she finishes her thought, one of her phones starts ringing. She answers it as she climbs into her car and heads off to her next appointment.

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