• Introduction
• Improving Care for the Chronically Ill
  • Improving Care of the Chronically Ill
  • Team Care Recognizes and Embraces Complexity
  • Team Care is Cost-Effective Care
  • Making Team Care the Standard of Care
• History of Commitment to Team Care
• Team Care Models
• Model 1: Care Transitions
  Improving Transitions Across Sites of Geriatric Care
  • Model 1: Care Transitions
    Improving Transitions Across Sites of Geriatric Care
  • The Four Pillars of Care Transitions
  • Illustration: Care Transitions Model
  • Measuring the Success of Care Transitions
  • Moving the Model from Two Sites to 100
  • A Transition Coach Makes Recovery from Surgery Faster, Easier
• Model 2: Care Management Plus
  Using Technology to Improve Outpatient Care for Older Adults
  • Model 2: Care Management Plus
    Using Technology to Improve Outpatient Care for Older Adults
  • Description of the Model: Care Management Plus
  • Illustration: Care Management Plus Model
  • Measuring the Success of Care Management Plus
  • The National Search for Quality Health Care Finds Care Management Plus
  • Tracking Care Over Time Helps Avoid Serious Disability
• Model 3: Senior Health & Wellness Clinic
  Managing Care of Older Patients in the Clinic by Fostering Team Care
  • Model 3: Senior Health & Wellness Clinic
    Managing Care of Older Patients in the Clinic by Fostering Team Care
  • Senior Health and Wellness Center: Total Care Under One Roof
  • Team Care Approach at Senior Health and Wellness Center
  • Measuring the Success of Senior Health and Wellness Clinic
  • Illustration: Senior Health and Wellness Clinic
  • Customizing Team Care to Work Locally
  • From Clinic Volunteer to Clinic Patient, But Always a Member of the Team
• Model 4: Virtual Integrated Practice
  Implementing Team Care Across Practices and Virtually
  • Model 4: Virtual Integrated Practice
    Implementing Team Care Across Practices and Virtually
  • Virtual Integrated Practice: The Community Response
  • Measuring the Success of Virtual Integrated Practice
  • Illustration: Virtual Integrated Practice Model
  • Building Community Capacity
  • VIP: A Seamless System of Resources
• Senior Resource Team
  Important Role Foundations Play in Taking Risk
• Looking Toward the Future of Team Care

Featured Initiative:

Senior Health and Wellness Clinic Model:

Team Care Approach at SHWC

An elderly patient made recurring visits to the emergency room at Sacred Heart Medical Center with minor complaints or questions about his medications. The SHWC was notified through the electronic medical record and the patient was asked to come to the clinic for an appointment with the lead physician, Jeffrey Larkin, MD, to reconcile his medications. Every time the patient came in he either had different medications or forgot to bring his medications. It was apparent to Dr. Larkin that the patient was having memory problems, and tests confirmed the diagnosis of Alzheimer's disease. Dr. Larkin asked the patient's wife to accompany him to the next appointment and then asked her to help manage his medications. “I wanted to make sure I knew what the patient was taking before starting him on medications for Alzheimer's,” said Dr. Larkin.

The medications continued to be taken incorrectly. The patient's wife was a patient at the clinic, but she was not Dr. Larkin's patient. Dr. Larkin decided to discuss this case at the weekly care conference. In consultation with the team, which included the wife's physician, it became evident that the patient's wife was also exhibiting memory problems. Because of the care conference, the wife was brought in for testing and was diagnosed with dementia. The social worker was able to work with family members to arrange for proper care of the couple. The pharmacist got involved with a medication review to ensure the patient was on the proper regimen for his multiple health conditions and that it was being followed. “With a team approach, we were able to come up with a solution for this patient that I wasn't able to achieve alone,” said Dr. Larkin. “This is a common scenario,” he said.

“The Senior Health and Wellness Clinic is always pushing the envelope to make patient care better. I absolutely look forward to coming to work every day.”Bradley T. Johnson, RPh,
CGP, CDM, FASCP
Clinical Geriatric Pharmacist,
PeaceHealth, Eugene, OR

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