In a red brick building that was once an elementary school, West Durham residents can visit the Lyon Park Clinic for their health care needs. On the opposite side of town, the Holton Wellness Center is located inside a career and resource center just steps away from patients’ homes. In a charming gray house that blends into the surrounding neighborhood, patients near Duke University’s East Campus can easily walk to the Walltown Neighborhood Clinic. These clinics fit seamlessly into the communities that surround them and have grown over the past eight to 15 years through the leadership of the longtime clinicians who practice there.
Through a collaboration between the Duke Division of Community Health and Durham’s Lincoln Community Health Center, the community clinics are led by three advanced practice providers (APPs) who each feel that their art in practicing medicine has grown stronger through connections made with smaller communities in Durham. Diane M. Davis, MPH, PA-C; Kaitlyn Granda, PA-C; and Virgil Mosu, FNP-C, MSN, have seen the benefits of developing relationships with patients who can walk through the clinic doors regardless of where they come from, what language they speak or if they have insurance.
“People say all the time that they just walked in for their visit today, and that’s great,” says Granda, who works at Walltown Neighborhood Clinic. “To be able to take the bus here, to be able to walk here, to be able to stop in at 8:15 one morning because you feel sick — and if you’re my patient you know I’m going to see you — it makes such a difference.”
The idea for creating the community clinics first developed in 2002 out of a university-neighborhood initiative that was implemented by Nannerl O. Keohane, the Duke University president at the time. The community asked for neighborhood health clinics and the Division of Community Health in the Department of Community and Family Medicine was asked by the university to design them. The division sought the support of Lincoln Community Health Center, which agreed to become a partner so its services could be expanded to the vulnerable population of Durham. Fred Johnson, MBA, assistant professor of community and family medicine and director of clinical and care management services for the Division of Community Health, says department and division leadership believed that APPs should be hired to work as the lead clinicians in these clinics. According to the American Academy of Neurology, APPs are qualified and specialized non-physician care professionals who provide care and treatment while working under close physician supervision. They are certified to perform many of the same tasks as a doctor.
“We decided to hire APPs for two fundamental reasons: programmatic and operational,” Johnson says. “We wanted to demonstrate ability and effectiveness of independent APPs, and at the time their wage and benefit expenses were dramatically less than a starting M.D.”
Lyon Park Clinic
With physician assistant Diane M. Davis serving at the lead clinician, Lyon Park Clinic was the first community clinic to open its doors in 2003. Davis was the first full-time bilingual primary care provider in Durham, immediately drawing patients from the Hispanic community. Before coming to Duke, Davis worked at a health center through Piedmont Health and was drawn to the idea of practicing in a smaller environment after reading about the partnership between the Division of Community Health and Lincoln Community Health Center.
“I liked the idea of small, because when I started out with Piedmont we had just opened a clinic in Burlington and it was tiny, but then it grew really large,” Davis says. “I really like small, and so I came to talk about [the clinic] and I thought it sounded like a really neat idea.”
Lyon Park Clinic, 1313 Halley St., opened in West Durham inside the Community Family Life and Recreation Center at Lyon Park, a building that was an elementary school in the 1930s and had since been converted into a center for the local community after years of sitting empty, dilapidated and unused. When the clinic opened, it consisted of only two exam rooms, a small office and lab space in the back, and a tiny administrative center and waiting room at the front. Davis says she enjoyed the small space and autonomy she had at the clinic, feeling that with a clinic built in the community available to patients “we get the benefit of the tiny, personal space and relationships with patients, but our patients also get the benefits of all the things a larger health clinic like Lincoln can offer.”
Seeing about 20 patients a day, Davis loves having a smaller work environment and being able to set the tone and expectations of the clinic. Additionally, Davis became the associate medical director of clinical services in 2012 and in this role has worked to improve communication and integrate services between Lincoln Community Health Center and the three community clinics.
Walltown Neighborhood Clinic
Over the course of the next year, the Lyon Park Clinic expanded to allow for a larger waiting room and administrative center, and the development of a second community clinic in the Walltown neighborhood near Duke’s East Campus began. Physician assistant Kaitlyn Granda was hired as the lead clinician at the Walltown Neighborhood Clinic, 815 Broad St., in September 2004 after practicing for four years at Lakewood Pediatrics and Family Medicine in Durham. After the clinic opened in January 2005, Granda says she had to adjust to her new working environment.
“I quickly became aware of what it was like to care for folks who have no insurance, who are underserved in our population, and for the first time I worked alone,” Granda says. “I wasn’t sure how I was going to like it, but I just really liked the patient population, I really enjoyed having Duke and Lincoln support me as these bigger organizations, but yet have lots of autonomy by myself.”
Over the past 12 years, Granda has developed a commitment to serving a diverse patient population, considering patients’ race, language and socioeconomic status as important barriers or access points for medical care.
“I love coming to work in this little house off Broad Street,” Granda says. “It’s quiet, it’s calm, we have a really efficient working system and I’ve seen the same families, the same patients, for over a decade, so I love that.”
Holton Wellness Center
Four years later, family nurse practitioner Virgil Mosu, MSN, began working as the lead clinician at Holton Wellness Center, 401 N. Driver St., which opened in January 2009 at the Holton Career and Resource Center in East Durham.
After working at the Pre-Operative Screening Unit at Duke University Hospital for a year, Mosu was intrigued with the position at Holton Wellness Center due to his desire to deliver more hands-on care to patients, as he had done while working as a nurse practitioner in a community health center in Florida.
“I like being involved in the hands-on, day-to-day care of my patients,” Mosu says. “It’s part of our job to take those 15 to 20 minutes to talk to and educate them with the facts they need to take their medications, eat and exercise properly.”
Initially thinking of practicing in cardiology, Mosu was instead inspired to work in community medicine due to his past personal experiences with not having insurance and not speaking English. Born and raised in Romania, Mosu first came to the United States when he was 13 years old, and 30 years later speaks both English and Spanish, in addition to his native Romanian, and is dedicated to caring for the underserved and uninsured through a community clinic.
“After being at Duke for almost 10 years, I was influenced to stay here because I felt I could connect with where many of the patients are coming from,” says, who sees almost 30 patients a day during 12-hours shifts. “I know what it’s like to be in their shoes, and I also honestly love the schedule and environment of the clinic.”
Long-Lasting Patient Relationships
Davis, Granda and Mosu all agree that one of the most rewarding aspects of working in the community clinics has been the development of stronger ties and relationships with their patients and the surrounding communities.
“I have patients that I have been seeing for 15 years; we know them, we know their husbands and wives, we know their children and their grandparents,” Davis says. “And it is truly a lovely way that medicine should be.”
Johnson agrees that a core tenant of primary care is establishing effective and efficient relationships with people, beginning with knowing the whole person.
“A clinician who has a long-term relationship with a patient is capable of guiding a patient through bumps and bruises as well as serious conditions,” Johnson says. “The partnership between patient and provider becomes as organic as butter knife and butter.”
Davis says that working in a small setting has allowed her and the rest of the Lyon Park Clinic staff to really get to know one another, and stresses the importance of being able to see a patient when they walk in. She recalls an occasion when a patient walked into the Lyon Park Clinic at 4:30 p.m. on a Tuesday having trouble breathing. Although the clinic closes at 5 p.m. and there were no appointments left, the staff had known the patient for a long time, were familiar with her medical history and were able to utilize their flexibility to get her the help she needed.
“She has no money, she has no transportation and she came here on the bus,” Davis recalls. “But she knew that she could come here and walk in the front door and have somebody talk to her and find out what’s wrong with her.”
Mosu also emphasizes the importance of community and what patients like to see in their relationships with health care providers.
“The best compliment that a new patient can give you is when their referral is from friends or family here in this community,” Mosu said. “I can point out the houses that are homes to the patients who come in to see us, and they can just walk right into the clinic with their families.”
Diversity in the patient population is one of the reasons Granda enjoys working at Walltown Neighborhood Clinic. She sees patients who have significantly higher incomes and patients who have been chronically unemployed, patients from right across the street and patients from an extensive community of families from Africa who come to visit their children in the United States. Granda says that seeing patients from different socioeconomic and psychosocial backgrounds can be challenging, though.
“Maybe the way we take care of ourselves is not the way they want to take care of themselves,” she says.
Granda recalls one patient: an older African-American man who had diabetes and continually came to see her at Walltown despite a wariness of “white people medicine” and a lack of blood pressure management. Over time, Granda came to understand that the patient was seeing her to talk about his desire to die at home, and after receiving a call from the emergency department about him, she explained to the ED to do nothing and let him go home.
“I would tell them he wants to die at home, let him go home, and that’s what happened,” Granda recalls. “He was asking me to help him die the way he wanted to.”
With this diversity in patient population and backgrounds, Mosu says that it is important for nurse practitioners and physician assistants to have patience while working in these community clinic environments.
“In a private practice the patients may be better insured or better educated; the people take more charge of their health care,” he says. “Sometimes in underserved areas or underserved populations they are less likely to take care of themselves because they are more focused on paying their rent or buying food for the month.”
The Future of Advanced Practice Providers in Community Clinics
With an increasing demand for advanced practice providers (APPs) — nurse practitioners and physician assistants — in the health care industry, community clinics in rural or underserved areas are playing an important role by filling a gap. According to research from the Health Resources and Services Administration, the supply of primary care NPs is projected to increase by 30 percent and the supply of primary care PAs is projected to increase by 58 percent in 2020.
Davis recalls that there were only three or four APPs in the city of Burlington when she started working with Piedmont Health in the mid-1990s.
“There has obviously been a huge increase for us and I think the increase is also related to people knowing how to use APPs,” Davis says. “This model that we have in the community clinics is actually very unique, because most of the time there are no M.D.s onsite. We are able to practice more independently.”
All three providers see their clinics playing an important role in the future of their patients, the communities they serve and their careers. Although one of the most important benefits for underserved populations has been regular improvement in their health care over the years, Mosu still sees opportunities for improvements in the future.
“I think we provide very good customer service and a good amount of education to patients, and I think overall we made a difference in the community and the area,” he says. “But I think we can potentially do better. We could always do a better job with outcomes, but it also takes a lot of patient cooperation, good food and exercise, and patience.”
These opportunities may be dependent on the future growth of the role of APPs in community clinics, as Davis believes that providers like herself have developed more experience with managing people and being creative in their practice.
“I think that community clinics are a great setting for APPs to do first, because it gives you an idea of what the reality is for a lot of people in this country,” Davis says. “If your first job is in private practice or as a sub-specialist, you don’t know what life is like for your patients, and if you work here first you’re really going to understand where your patients are coming from and that helps you take better care of them.”
Davis, Granda and Mosu all say they are committed to serving their longtime patients and the communities that surround them for many years to come.
“I’m committed to these patients because I’ve been seeing them for so long and they know me,” Granda says. “As I grow older, I want to know who my provider is; I want to know somebody who has been seeing me through these different parts of my life, and I haven’t found one yet. I want to try to be that person for my patients and I think this clinic can continue to serve this community for many years to come.”
For more information about the community clinics, visit http://communityhealth.duke.edu/clinics.
Natalie Briggs is the communications intern for Duke Community & Family Medicine. She is a junior at UNC-Chapel Hill majoring in journalism.