• 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:

Improving Care for the Chronically Ill

Chronic illness disproportionately affects older adults. Most Medicare beneficiaries (82 percent) have at least one chronic condition. Two-thirds of these older adults have several chronic conditions, with 24 percent coping with four or more.⁵ These older adults can suffer from the fragmented nature of the health care delivery system in numerous ways. For example, medical errors, which are often caused by faulty systems, injure a million or more people each year and are the cause of about 100,000 deaths, according to a widely publicized report by the Institute of Medicine in 2000.⁶

Older adults with chronic illnesses are particularly vulnerable. Even with no chronic health conditions, older adults typically fill about 10 prescriptions each year for various health problems. For a person with five chronic illnesses, the number of prescriptions jumps to 57. Drug interactions and mistakes in administration by both patients and providers can have serious health consequences. More than a million patients are injured annually from medication errors, according to the U.S. Food and Drug Administration. Nearly 50 percent of deaths caused by medication errors occur in older adults.

In the current disease-focused system, patients see different physicians for treatment of each ailment: a cardiologist for heart disease, an endocrinologist for diabetes, an ophthalmologist for glaucoma, and so on. The high quality care delivered by each provider can easily suffer when physicians do not communicate with one another and fail to coordinate care.

The following scenario demonstrates how the health care system can fail the most vulnerable patients:

At age 80, Mrs. Jones, a widow who lives by herself, takes medications for arthritis, high blood pressure, high cholesterol, glaucoma, and osteoporosis. At a family get together, she faints and is rushed to the hospital where it is discovered that her blood sugar levels are high. She is diagnosed with type 2 diabetes. The doctor in the hospital gives her a new prescription and some brief instructions about diet and exercise. He also tells her to make an appointment with her primary care doctor and a nutritionist.

Mrs. Jones, upset about being in the hospital and rattled by the new diagnosis, does not remember all of the instructions. She does not know a nutritionist to call and does not change her diet. She starts to take the new medication, but it doesn't make her feel any better. Because of her difficulty walking, she decides to put off seeing her doctor until she is feeling stronger.

Mrs. Jones gets weaker and more fatigued. Her vision becomes blurry and she experiences a tingling sensation in her hands and feet. When Mrs. Jones's daughter comes to check on her mother, she discovers her mother in distress and calls for an ambulance. Mrs. Jones is readmitted to the hospital. Her diabetes is not under control, and now she is unable to walk as a result of deconditioning. She is now having difficulty managing for herself at home.

Older adults coping with multiple chronic medical conditions require the most intense management of conditions and coordination of care, yet they are the very patients who often slip through the cracks and wind up in jeopardy as a result of the system that is supposed to serve them. Patients who present the greatest challenges often have multiple chronic illnesses coupled with cognitive impairment, depression, or physical limitations.

In an ideal health care system, care for these vulnerable older patients would be provided through interdisciplinary teams. Communication among physicians, nurses, social workers, pharmacists, dieticians, physical therapists, and others, would utilize well-designed information technology systems. Patients and family caregivers would be treated as integral members of the team, rather than as passive recipients of medical procedures and advice. Well-informed patients would become motivated to actively take part in their own healing and wellness.

When Mrs. Jones receives health care from a well-coordinated interdisciplinary team the result is very different:

Mrs. Jones has a primary care physician and also sees specialists for her chronic conditions. Her care is coordinated with an efficient information technology system that facilitates communication among all of her health care providers. After fainting at the family party, Mrs. Jones goes to the hospital and receives the diagnosis of diabetes. Her primary care doctor is alerted to the hospitalization and a receptionist calls Mrs. Jones to schedule a follow-up appointment. The doctor, who has limited time to educate Mrs. Jones about the management of diabetes, engages other members of the health care team. A nutritionist is consulted and takes time to educate Mrs. Jones about the dietary requirements for a person with diabetes. A pharmacist reviews all of the medications Mrs. Jones is taking and makes suggestions to the physician for combinations of drugs that will not adversely interact with one another. The pharmacist also reviews all of the instructions for each of the medications with Mrs. Jones. Because Mrs. Jones has difficulty walking, making it hard to get to the clinic, a social worker connects her with a local senior center that offers van rides to older adults.

Mrs. Jones's health improves. The deterioration in her ability to walk was partly due to fatigue brought on by her diabetes, and now she feels well enough to attend an exercise program at the senior center. Not only does Mrs. Jones stay out of the hospital-she feels stronger and more confident. She is able to join her daughter and grandchildren on an outing to her favorite botanical garden.

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5- Wolff JL, Starfield B, Anderson G. Prevalence, expenditures, and complications of multiple chronic conditions in the elderly. Arch Intern Med 2002;162:2269-76.
6- Leape L, Member, Quality of Health Care in America Committee, Institute of Medicine, and Adjunct Professor, Harvard School of Public Health. Concerning Patient Safety and Medical Errors. Statement before the United States Senate Subcommittee on Labor, Health and Human Services, and Education. January 25, 2000.