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Just for Us: An Academic Medical Center–Community Partnership to Maintain the Health of a Frail Low-Income Senior Population

Correspondence: Address correspondence to Susan D. Yaggy, MPA, Chief, Division of Community Health, Department of Community and Family Medicine, Duke University Medical Center, Box 2914, Durham, NC 27710. E-mail: yaggy002{at}mc.duke.edu

Purpose: To promote health and maintain independence, Just for Us provides financially sustainable, in-home, integrated care to medically fragile, low-income seniors and disabled adults living in subsidized housing. Design and Methods: The program provides primary care, care management, and mental health services delivered in patient's homes by a multidisciplinary, multiagency team. Results: After 2 years of operation, Just for Us is serving nearly 300 individuals in 10 buildings. The program is demonstrating improvement in individual indices of health. Medicaid expenditures for enrollees are shifting from ambulances and hospital services to pharmacy, personal care, and outpatient visits. The program is not breaking even, but it is moving toward that goal. The program's success is based on a partnership involving an academic medical center, a community health center, county social and mental health agencies, and a city housing authority to coordinate and leverage services. Implications: Just for Us is becoming a financially sustainable way of creating a "system within a nonsystem" for low-income elderly persons in clustered housing.

Key Words: Care coordination • In-home care • Subsidized housing • Sustainability