provides the majority of ongoing support for the program. Through Just for Us, an interdisciplinary team
of providers serves clients in their homes, providing medical care, management of chronic illnesses, and
case management. Each participant receives a home visit every 5 weeks unless there is an acute episode
or a hospital discharge, for which a visit is scheduled immediately. Visits include medication
reconciliation, social issues, support services, chronic disease management, and post-hospital care. The
health care team consists of a clinical provider (PA, NP or MD), occupational therapist, registered
dietitian, social worker, phlebotomist, and community health worker.
In late December of 2019 reports of carbon monoxide poisonings began at the McDougald Terrace
Apartment Complex. By early January 2020 the Durham Housing Authority had relocated hundreds of
residents to 15 hotels across Durham. The Just for Us team deployed to provide health care for
residents across the 15 hotel sites during January and February. Almost all of the Just for Us in home
visits ceased in March of 2020 as a result of COVID 19. As a result, the JFU team conducted frequent
well-check calls and provided telehealth services (via phone/video visits).
Neighborhood/Community Clinics: DUH in partnership with Lincoln Community Health Center
collaboratively operates three community health clinics; the Lyon Park Community Clinic, the Walltown
Neighborhood Clinic and the Holton Wellness Center. The clinics were designed to provide primary
care, health education, and disease prevention to the underserved populations of Durham. The clinics
provide medical care for persons with and without health insurance. Those without insurance are seen
based on a sliding fee scale. No patient is denied care based on inability to pay for services. The Lyon
Park Clinic was the first of the collaborative neighborhood clinics, opening its doors for patient care in
April 2003. The Walltown Clinic opened in January 2005 and the Holton Clinic opened in August 2009.
Each clinic received start-up funds through a Duke Endowment grant. Clinics generate revenue through
a contract with Lincoln Community Health Center and receive significant support from DUH. The clinics
operate as Family Medicine Practices and are open 5 days a week. Staffing includes Physician Assistants,
Nurse Practitioners and Family Physicians, who serve as supervising doctors. Each clinic is supported by
nursing staff: Certified Nursing Assistants, Licensed Practical Nurses, or Certified Medical Assistants and
a staff assistant. The staff assistant performs all administrative tasks for the clinic including answering
incoming phone calls, registration, scheduling, etc.
At the onset of Durham’s stay-at-home orders, the Holton Wellness Center had to close as it is located in
a school and multi-purpose center. The team was able to move to the other neighborhood/community
clinic locations and all of the neighborhood/community clinics added telehealth services (via
phone/video) in addition to in-person visits.
FY20 PROGRESS: In spite of the disruption caused by COVID 19, the Southern High School Wellness
Center, Just for Us, and the Neighborhood/Community Clinics provided more than 12,000 clinical
encounters in 2020.
FY21 PLANS: The Southern High School Wellness Center, Just for Us, and the Neighborhood/Community
Clinics hope to return to pre-pandemic levels of clinical encounters of 13,000+
3. Poverty
Poverty has a strong impact on health and is an important concern for Durham residents. Research now
shows that even the risk of an adverse change in material conditions — economic and housing