• 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:

Customizing Team Care to Work Locally

A team approach to geriatric care must be adapted to the needs and culture at each institution. Dr. Stock and his colleagues invite those who are interested in the SHWC model, or aspects of the model, to a site visit. They provide detailed written materials and often visit the site where the model will be implemented to discuss how it can be efficiently incorporated within the existing structure and to provide technical assistance for implementation. This one-on-one assistance can be particularly helpful for convincing sometimes reluctant administrators of the benefits, both clinical and financial, of the model.

Rosemary Laird, MD, Health First Aging Institute, Cocoa Beach, Florida, found this individualized assistance particularly useful. She had to surmount some common hurdles. Dr. Laird is a geriatrician in a small, community-based, not-for-profit health system, and several years ago she was looking for ideas to improve care for her patients. She met Dr. Stock at a meeting of the American Geriatrics Society and became aware of his work on team care in a geriatric clinic. With advice and counsel from Dr. Stock, she began to implement some of the concepts of the SHWC model in her clinic, and was pleased with the results. When a new administrator was hired, all of these concepts were scrapped. Undaunted, Dr. Laird began calculating the lost revenue resulting from having shut down the SHWC initiatives.

A year later, armed with the data she had collected and an article Dr. Stock and his colleagues had published in the Journal of the American Geriatrics Society, Dr. Laird convinced the leadership at the Health First Aging Institute to engage in a formal relationship with the group at PeaceHealth and to reinstate aspects of the model. For example, they broadened their pool of providers, increased revenue-generating clinical services (such as adding a foot care clinic), and have regular team meetings in one of their two clinics.

“Administrators assume that you can't take care of older people cost effectively,” said Dr. Laird. “The group at PeaceHealth were really effective in helping me to communicate with administrators and convince them that it is possible.” Individualized assistance from Lorelei Cesario, Director of Senior Business Development, The Gerontology Institute, PeaceHealth Oregon Region, on the financial aspects of the model was instrumental in persuading administrators that it made good business sense.

“If you can't convince an administrator and make the business case, everything just stops,” says Dr. Laird.

The PeaceHealth SHWC model has found converts in a variety of health care systems. For example, when Karol Attaway, Vice President of Operations, Healthcare Partners Medical Group, in Southern California, was designing a home care program for older patients with chronic illness who were not able to travel to the clinic, she looked for models of interdisciplinary team approaches. A site visit to the PeaceHealth SHWC provided valuable insights on managing chronically ill patients. Ms. Attaway was especially impressed with the care collaboration meetings that include everyone in the clinic, including the front office staff, and she has incorporated this into the home care program. She was also interested in the written materials the SHWC had created for patients, which include photographs and bios of the physician. “We're going out to patients' homes, so we thought it was a great idea to mail these materials, with the physician's photograph, ahead of the visit,” says Ms. Attaway.

Interest in the SHWC model is generated from a variety of sources, including professional networks and visibility at relevant meetings. Dr. Stock and the group at PeaceHealth have been invited to give 25 presentations over the past five years to approximately 1,000 clinicians in venues such as the American Geriatrics Society, National Patient Safety Forum, Institute for Healthcare Improvement, American Medical Association, National Council on Aging-American Society on Aging, Gerontological Society of America, Agency for Healthcare Research and Quality, National Institute for Case Management Clinical Case Management Conference, and Society for Social Work Leadership in Health Care. PeaceHealth has consulted with or hosted site visits for 35 health care organizations from the United States and Canada.

In addition to written materials that aid in the implementation of the SHWC team care concepts, the SHWC team also developed an assessment tool called the Team Development Measure (TDM). The TDM (available on the SHWC Web site www.teammeasure.org) measures the degree to which a team has in place the components needed for highly effective teamwork and how firmly these components are in place.

“This survey tool can be used as a measure of quality and it can also be used to provide feedback in order to improve 'teamness,' so it can be a quality improvement measure,” says Dr. Stock.

Dr. Stock and the group at the SHWC also developed the “Team Bundle.” This is a description of the four components that must be in place for successful implementation of the model. These are:

1. Healthcare leadership must make a commitment to the team care approach.
2. Team development measures should be used to provide feedback to the team about "teamness" and areas for improvement.
3. There needs to be a focus on training clinic staff to communicate better amongst themselves.
4. All teams need to practice team skills, which is one of the roles of the weekly patient care conference.

To encourage even wider dissemination of the model, SHWC is developing a business model based on demonstrating that the SHWC team care model provides higher quality cost efficient care, and that it can realistically be implemented in a community health system outside of an academic setting. The successful implementation of this model has allowed the group at PeaceHealth to leverage the Hartford Foundation support and receive additional funding from several sources. These include the following:

1. Robert Wood Johnson Foundation
2. Agency for Healthcare Research and Quality
3. Sacred Heart Medical Center Foundation
4. Collins Foundation
5. Northwest Health Foundation
6. Spirit Mountain Community Fund
7. Lane County United Way 100% Access Coalition

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