• 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:

Virtual Integrated Practice Model:

VIP: A Seamless System of Resources

Maria Guadalupe (Lupe) Carreto and her husband Fernando, who both have diabetes and hypertension, were advised over ten years ago by their doctor to exercise as part of a comprehensive health plan. Lupe, who was working as a volunteer in the clinic of her physician at the time, realized that she and her husband were not the only seniors who needed a regular exercise program. Working with another volunteer and her doctor they set up a two day a week exercise program at a field house in a local park, originally for five to ten older adult clinic patients. Eventually, the director of the park noticed the group and incorporated them into a group called Seniors of Dvorak Park. The Chicago Park District now runs the exercise program with an exercise instructor sent by the Department on Aging, and the group has grown to over 20 people aged 70 to 85.

The Carretos attend exercise class in the Dvorak Park Field House located on the south side of Chicago. Without realizing it, Lupe, whose physician is Dr. Steven Rothschild, created an important community resource that has become part of Virtual Integrated Practice (VIP). "The theme of VIP is community partnership, using resources outside of the formal health system," says Dr. Rothschild, Principal Investigator of the VIP team care model.

Fernando and Lupe, now in their 70s, have been patients of Dr. Rothschild for over 20 years. As they developed chronic health conditions, their need for services beyond what the doctor is capable of providing grew. In addition to advising increased exercise, Dr. Rothschild also referred them to a community-based dietician. The dietician was particularly helpful to Lupe, teaching her what foods the couple should be eating and what to avoid. Lupe and Fernando also participated in group visits with other diabetes patients and were encouraged in the self-management of their health conditions.

Lupe and Fernando Carreto, both in their 70s, exercise twice a week as part of a comprehensive health plan.

The Carretos continue to get the word out about the exercise program to seniors in their community. For seniors with diabetes and other infirmities, this type of program is invaluable for maintaining and improving physical functioning.

“VIP is about building a seamless system of resources that allows us to get patients the services that we can't provide in the office,” says Dr. Rothschild. “It's about building an extension into the community or into other providers and putting them on a team.”

Next: Senior Resource Team: Important Role Foundations Play in Taking Risk ›