• 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:

From Clinic Volunteer to Clinic Patient, But Always a Member of the Team

Christa St.George provides a tour of the clinic to Darold Alexander. Having successfully recovered from spinal surgery, Ms. George tells every new patient on orientation what team care did for her, and what it can do for them. Every new patient treated at the Senior Health and Wellness Clinic (SHWC) begins with an orientation given by volunteer Christa St. George. Christa explains the team concept to patients, informs them about the different types of health providers available at the clinic and what each one does, and gives them a tour of the facility. “I tell them what we have, what we can do for them, and what we expect from them,” says Christa.

The patients are attentive and extremely grateful for the information. “People tell me this has never happened anywhere else they've been to for health care,” says Christa, who has a friendly, welcoming personality and thoroughly enjoys her work.

When Christa, who is 75, began to feel some tingling in her fingertips, she shrugged it off and continued giving patient orientations. But the morning she wasn't able to button her blouse, she decided to consult with the clinic's lead physician, Dr. Jeffrey Larkin. Dr. Larkin discovered numbness in both hands and some neck pain. An MRI of the neck showed a cancerous tumor in Christa's upper spinal column.

“Two days later, I was in surgery for seven hours, followed by four days in the intensive care unit and more than a month in an inpatient rehabilitation facility,” says Christa. With the help and support of different members of the interdisciplinary team, of which Christa, now as a patient, is a vital member, she has gotten through her ordeal, although she remains impaired.

Dr. Larkin credits, in part, the longer appointment times given to clinic patients for his ability to quickly get Christa the treatment she needed. “Spending more time with patients leads to more accurate diagnoses,” he says. “Christa's case could easily have been written off as carpal tunnel syndrome, but I had the time to spend with her and get it right.”

Even though Christa continues to have difficulty with walking and with hand coordination she has come back to the clinic as a volunteer to give patient orientations, now with a new perspective on the resources of the clinic to share with incoming patients.

St. George with Senior Health and Wellness Clinic physician, Jeffrey K. Larkin, MD.

Next: Model 4: Virtual Integrated Practice ›