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Grit and grace: James McDuffie’s journey to health

April 8, 2025

By considering the social and environmental conditions that influence health outcomes, ProHealth is helping to create a more inclusive and effective care delivery system for all.

When James E. McDuffie, 76, reflects on his life, it's shaped by hardship and survival. A line from John Steinbeck’s The Grapes of Wrath — "In the souls of the people, the grapes of wrath are filled" — captures a sentiment that mirrors James’s own experience.

Like the migrant workers in the novel, his journey was marked by a struggle for basic survival, driven not by choice but by necessity.

His hard work in the fields, years of laboring without the opportunity for education and lack of health care highlight a life shaped by systems that placed barriers at every turn.

As a ProHealth patient, he now benefits from a comprehensive care model that is helping address both his medical and social needs.

Social drivers of health

Social drivers of health — factors like the environments where people are born, raised, work and age — have a significant impact on overall well-being. They're estimated to account for 30-55% of health outcomes.

Addressing these factors requires a broad, multisector approach. However, primary care is in a unique position to make a real impact.

With its ongoing, trusted relationships with patients, primary care organizations can identify and address the social factors affecting health.

This requires a shift toward a care model that prioritizes prevention and coordination. At ProHealth Physicians, this shift is well underway.

The man of the house

Growing up in rural South Carolina, James’s life was dictated by the need to labor. As the only son in his family, he was expected to work the land.

“I started when I was just 6 or 7 years old. Working in the fields or bringing water for the family. That’s just what men did back then,” he adds matter-of-factly. “We picked and planted cotton. Beans and corn. We also cut down trees. Whatever was needed."

Like generations of men before him, education wasn’t a priority. "My 3 sisters all learned to read and write. I did first grade and that was it. I was the one left behind.”

It wasn’t until the age of 18 — when James left home to find better opportunities in Connecticut — that his journey took a new direction.

“In South Carolina they didn’t give no jobs to illiterate folks like me. When I came here, they sent me back to school to do machinery. I ended up working for over 50 years. I did guns and ammunition. My last job was doing piping, the one that’s used for cooling down buses."

Yet, despite working for decades to build a good life for himself, he still faced serious challenges. “I have issues with my kidneys. Prostate cancer. All of that.”

To meet his health care needs, James relied on Medicare Part A, which only covered hospital stays. Any other health expenses, like regular doctor visits or prescriptions, had to be paid out of pocket.

Over time, undiagnosed conditions like diabetes and hypertension took a toll on his health. His limited insurance — together with the inability to navigate the health system — left him struggling to get the care he needed.

A nurse at heart

From a young age, Joanne Foss, MSN, RN, CMC, CDP, knew patient care was what she wanted to do. She started volunteering at a local hospital when she was 13. Soon she was in love with the hum of patient care.

"By the time I finished high school, I couldn’t imagine being anywhere else," she says. "As soon as I graduated, I got a job at that very same hospital and entered Saint Joseph College — now Saint Joseph University — to pursue a bachelor’s in nursing.”

One of 5 children, Joanne had a close relationship with her dad.

“He had his own scrap metal recycling business. He did not finish high school, but he liked to say that he had a Ph.D. in life. He was very good with people. He taught me to listen. We have 2 ears and one mouth for a reason.”

Joanne carried that wisdom into her nursing career, which spanned subacute, acute, rehab and long-term care. Along the way, she noticed a troubling pattern: patients and families often got lost in the complexity of the health care system.

Seeing the potential to bridge that gap, she earned her care management certification and formally ventured into the care coordination field.

“In 2007, I opened my own care coordination business. I sold it successfully in 2019, but felt I still had too much good to give to simply retire. I felt I was still too young to just stay home. That’s when I took the job at ProHealth. I am a nurse first and I like to mentor and lead. This role helps me do that.”

Fighting the odds together

Case managers play a vital role in guiding individuals through the complexities of health care systems, especially when systemic barriers make access to care more challenging.

Their work goes beyond administrative tasks like filling out forms or making referrals. It's about restoring dignity, advocating for change and ensuring that everyone has a fair chance to live a healthy, fulfilling life.

Joanne’s experience with James perfectly illustrates this.

“James came to me as a person who needed help with Medicare. He had hospital coverage but didn’t realize he had missed out on Medicare Part B because he couldn’t read. The same issue occurred with Part D," she shares.

This highlights how case management not only addresses health care needs but also helps navigate barriers like illiteracy or lack of awareness that prevent people from accessing their full entitlements.

Through a patient-centered approach, case managers ensure individuals receive the care they truly deserve.

James himself speaks highly of the support he receives:

“My old doctor tried to help me because I couldn’t read or write. But Joanne is better. At the doctor, they could only help me when I was in the office. I can call Joanne any time, and she knows my medicines and stuff. She talks to you in a way that you can understand. I don’t know where I’d be if I couldn’t talk to her. She gives good advice, and she’s helped me stay healthier, really.”

Joanne, in turn, finds inspiration in James's resilience:

“I see a little bit of my dad in him — how polite he is, how he gets around barriers. I am inspired by the gratification I get from seeing patients overcome barriers, live healthier lives and succeed. James inspires me.”

Setting the stage for equitable, patient-focused care

With a growing care coordination team of 9 individuals, including nurses and social workers, ProHealth Physicians continues to champion a holistic, patient-centered approach to care.

In close partnership with our clinicians, this dedicated team has been pivotal in improving patient outcomes.

As of August 2024, our commercial insurance and Medicare populations have shown positive trends —compared to 2023, hospital admissions are down by 7%, readmissions have decreased by 20% and ED visits have remained stable.

By addressing not only health concerns but also the broader social drivers of health, we are working to ensure more equitable access to care and improved well-being for all.

Together, we are setting the stage for better health outcomes and a more inclusive health care system.

The journey to improving health outcomes is ongoing — and we're proud to play an essential role in shaping this future.