• 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:

Introduction

For thirty years, experts have warned that the United States' health care system, which is focused primarily on acute care, is unprepared to provide adequate chronic care for the aging “baby boom” generation. Despite these admonitions, America's health care policies and providers have not focused on chronic care. Its hospitals, nursing homes, outpatient clinics, and home care agencies still operate as uncoordinated silos and the quality and efficiency of chronic care in America remain far from optimal.

The cost of fragmented, inefficient chronic care is high. Medicare beneficiaries with four or more chronic conditions account for 80 percent of Medicare spending,¹ which totaled $402 billion in 2006.² American medicine stands at a worrisome crossroads as the first baby boomers near retirement age. Without prompt transformation, chronic care in America will soon become unsustainably expensive. Re-designing primary care to provide high-quality chronic care requires new and realistic strategies.

To help bridge the gap between the growing need for high-quality chronic care and the present fragmented, acute care-oriented delivery system, the John A. Hartford Foundation has made a long-term commitment to fund the creation and dissemination of new conceptual models of chronic care for the nation's older adult population. At the heart of an effective geriatric chronic care system is a strong interdisciplinary team. Studies have shown that innovations in interdisciplinary team care, enhanced decision support, improved clinical information systems, support for self-management, and better access to community resources can improve clinical and/or financial outcomes in outpatient settings,³ in the home, and during transitions between sites of care.⁴

Over the past two decades, concepts of interdisciplinary team care have been woven into many of the Foundation's grants in the areas of medicine, nursing, and social work. These concepts have been directly addressed in a series of initiatives starting in 1992 with the Generalist Physician initiative and culminating in current efforts to disseminate models of team care developed under the Geriatric Interdisciplinary Teams in Practice (GIT-P) grants. Four strong models of team care-the Care Transitions Intervention, Care Management Plus, Senior Health and Wellness Clinic, and Virtual Integrated Practice-have shown improvements in health care quality and cost, and are being actively promoted to achieve widespread adoption.

Bringing change to health care delivery is a difficult undertaking. The Hartford Foundation employs three core strategies in its efforts to transform the health care system to improve care: prove and promote innovations in health care delivery, articulate the financial impact and benefits to make the case for adoption, and shape the system to demand innovation.

The Hartford Foundation's commitment to improving the health of our nation's elders has led to significant shifts and broad dissemination of innovations across care settings. Through these efforts, the Foundation has a direct and major impact on the care of older adults across the country.
Next: Improving Care for the Chronically Ill ›
1- Wolff JL, Starfield B, Anderson G. Prevalence, expenditures, and complications of multiple chronic conditions in the elderly. Arch Intern Med 2002;162:2269-76.
2- Annual Report of the Board of Trustees of the Federal Hospital Insurance and Federal Supplementary Medicare Insurance Trust Fund. Paulson, H. M., Chao E., Leavitt M. O. et al (online). Available at http://www.cms.hhs.gov/ ReportsTrustFunds/downloads/tr2007.pdf. Accessed January 22, 2008.
3- Counsell SR, Callahan CM, Clark DO et al. Geriatric care management for low-income Seniors: A randomized controlled trial. JAMA 2007;98(22):2623-33.
4- Coleman EA, Min S, Chomiak A, Kramer AM. Post-hospital care transitions: patterns, complications, and risk identification. Health Serv Res. 2004;39:1449-1465.