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Improving Care for the Chronically Ill:

Team Care Recognizes and Embraces Complexity

The project development teams of the five Geriatric Interdisciplinary Teams in Practice (GIT-P) models recognized that care of patients with complex care needs can be both rewarding and cost efficient, contrary to what many health care professionals believe. At the core of good geriatric care are these elements: prevention, patient self-management, involvement of family caregivers, efficient use of information technology, and a strong inter disciplinary team.

In 1996, the multi-site Geriatric Interdisciplinary Team Training initiative demonstrated the feasibility of bringing medicine, nursing, social work, and other health professions students together to learn team skills and interdisciplinary practice in order to provide better care to older adults with multiple health conditions. Ideal team care involves consultation with the right provider at the right time and effective communication among providers to prevent avoidable complications, catch medication problems and other types of errors, and ensure patient safety.

Well-coordinated team care emphasizes team building and use of information technology to share information, coordinate care, and ensure efficient use of evidence-based guidelines. Team building activities help health professionals to work together more efficiently and information technology systems serve as a valuable aid to patient care. Ultimately, interdisciplinary team care can be very rewarding for health care professionals, who gain a sense of accomplishment when chronically ill patients improve.

Because patients with complex needs tend to see numerous health care providers in different settings, effective team care must extend to multiple care settings, including the hospital, hospital clinic, skilled nursing facility, physician's office, and other sites of care. Currently, 33 percent of care plans are not transferred between health care settings. Making matters worse, patients released from the hospital, and their caregivers, may be unprepared for their self-management role.

“Team care is not an endpoint; team care is one of the essential ways to improve care of the chronically ill,” says Eric Coleman, MD, Professor of Medicine, Divisions of Health Care Policy and Research and Geriatric Medicine, University of Colorado Health Sciences Center.
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