Four years ago, Promising Practices was a gleam in the eyes of a few forward-thinking people in the Duke and Durham community. Working collaboratively, Duke University Health System, the Durham County Health Department, Lincoln Community Health Center, and other "safety net" agencies within Durham fleshed out a promising premise: that by taking medicine out into the community, many controllable illnesses could be managed before they escalated into emergency-room crises.

Three years ago, with initial funding from Duke University Health System (DUHS), the county, the Kate B. Reynolds Foundation, and The Duke Endowment, Promising Practices launched itself into the community. Mid-level practitioners from Lincoln Health Center (working under contract to DUHS) began connecting with patients in four zip-code areas of Durham that had the highest incidence of visits to Duke Hospital's Emergency Department. The health care providers focused on asthma, diabetes, and hypertension—three diseases where evidence proves that careful monitoring, education, and early treatment clearly make a difference. In addition, the program offered home health education and nutrition support. "The beauty of this program was how it pulled together so many resources," says Jean Spaulding, who was instrumental in shaping the original idea and in obtaining the grant from The Duke Endowment. At the time, Spaulding served as vice-chancellor for Health Affairs.

Now, at the end of the initial three-year period, Promising Practices is evolving once more.

"Promising Practices, in its original model, is dependent upon grant funds from The Duke Endowment, the Health System, and other sources of funding," says Gary Stiles, chief medical officer for DUHS. "In order to continue to provide community service to the underserved of Durham, we are integrating Promising Practices into the community-based services offered by the Department of Community and Family Medicine and the division of Community Health."

Moving Promising Practices under the auspices of the Department of Community and Family Medicine (CFM) and the division of Community Health (a joint division of the School of Nursing and CFM) will allow the patients who are currently seen under the program to access the wider range of programs CFM is involved in. These include the LATCH program, Carolina Access, Just for Us (Elderly), school-based clinics, and community clinics such as Lyon Park (see sidebar). In addition, patients that CFM health care practitioners have been seeing in these community-based programs will benefit from the wisdom gained in running Promising Practices.

A quick discussion among some of the movers and shakers involved with Promising Practices elicits some nuggets of wisdom that are worth sharing more broadly:

• "It proved how a program can benefit from bringing together all the different threads in the community—fund-granting organizations, county health workers, academic clinicians, the Schools of Nursing and Medicine," says Spaulding, who now serves as a trustee of The Duke Endowment. "It has been amazing for me to watch it evolve."

• "Patients will welcome us into their homes," says Richard Liebowitz, who has served as the medical director of Promising Practices. "Health care teams can reach people who cannot get to the clinics. If you don't try to force it, you can overcome some of the distrust that may exist and provide quality health care to these people that they might not otherwise get."

• "You have to provide care for all of a person's problems," says Lloyd Michener, chair of the Department of Community and Family Medicine. "For example, you can't treat a person for asthma and ignore their complaints about other diseases. You have to treat the whole person."

• "Partnerships with the community are invaluable," says Mary Ann Black, director of community affairs for DUHS. "In particular, working with Durham County Human Services agencies and Lincoln Health Center brings a perspective and set of strengths that complement Duke's strengths. Since we began Promising Practices, we have made sure to partner with Lincoln on every community-based effort. The health problems of Durham are issues with which Duke needs to grapple with, but we shouldn't try to do it alone."

• "Sometimes, it isn't clinical care that patients need help with," says Susan Yaggy, chief of the division of Community Medicine. "Promising Practices underscored the fact that what many people need is help navigating health care. They need help making appointments, or getting to appointments, or understanding how to take their medicines. That's what a lot of our programs, such as LATCH and Carolina Access, are focusing on now."

Ralph Snyderman, MD, chancellor for Health Affairs and CEO/President of DUHS, who was intimately involved in the original idea of creating Promising Practices as a model of prospective medicine, believes everyone involved in Promising Practices has good reason to be proud. "What we have done at Duke is unusual. We have a growing partnership between an academic medical center and the community. It continues to evolve as we learn from our experiences. It focuses on thpersonalized needs of people, many of whom have no other access to health care. An important point is that we are engaged with the community as well. That is a key mission of a medical center: improving the health of our communities."