Improving Chronic Disease Mgmt in DPC: Building a Virtual Medical Neighborhood
The Problem As health systems grow larger and demand for specialty care increases, it is becoming increasingly important to embrace efforts to reduce care fragmentation
Primary Care/Ambulatory Care
A Three-Pronged Approach to Reducing HIV Transmission through Pre-Exposure Prophylaxis (PrEP)
Development of a three-pronged program to decrease HIV transmission and increase awareness in the Duke and Durham community, including the creation of a dedicated Duke PrEP clinic at Duke Medical center, educational promotion, and community outreach.
Highly-Individualized, Dedicated Onsite Care at the Duke Outpatient Clinic
Development of a highly individualized dedicated onsite care program at the Duke Outpatient Clinic.
IMPACT Model: Transforming Depression Care Management in Duke Medicine: The Collaborative Care Approach
Performing PHQ2 and subsequent PHQ9 on all patients that are having an annual visit or are in the primary care clinic for a post-hospital discharge visit. Based on the PHQ9 score, patients are connected to care management and virtually rounded on by a med/psych attending.
Patient-centered Home Transplant
Provide patient-centered home transplant (PCHT) to improve patient safety, clinical efficacy, and value for hematopoietic stem cell transplantation (HCT) patients.
Breast Cancer Caremaps
Create a customized Caremap driven by EHR data and presented in an infographic format to support an ‘at-a-glance’ reference to complex treatment options, decision points and timelines upon diagnosis.