• 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:

Looking Toward the Future of Team Care

Overcoming the deficiencies of a health care system in which care for older patients with chronic illness is not well-coordinated among interdisciplinary teams of providers requires nothing short of a transformation of the health care system. Such a transformation may be on the horizon as the Centers for Medicare and Medicaid Services (CMS) confronts the reality of a growing number of Medicare beneficiaries-the leading edge of the baby boom generation is about to turn 65. Driven by an imperative to rein in costs, proposals that promise to improve care while lowering costs are receiving greater reception. These proposals include increased use of health information technology systems and programs to more efficiently manage the care of people with multiple chronic conditions.

To support quality improvement in the care of Medicare beneficiaries, the CMS is developing and implementing many quality improvement initiatives. These include pay-for-performance and the medical home, amplifying twenty years of Hartford Foundation efforts and accomplishments. Pay-for-performance means that payment is aligned with quality rather than the number of tests and procedures performed. Recognizing that many opportunities for quality improvement are patient-centered and cut across settings of care, CMS is also pursuing the medical home concept to provide improved care coordination for patients with chronic illnesses. Pay-for-performance and medical home are in the early stages of development, and the CMS is still determining the best methods of approaching a comprehensive program. This represents an opportunity for the team care models funded by the Foundation to play an important role.

CMS also promotes quality care through the Quality Improvement Organization (QIO) Program, which consists of a national network of 53 QIOs. According to the CMS, “QIOs work with consumers and physicians, hospitals, and other caregivers to refine care delivery systems to make sure patients get the right care at the right time.” Echoing the six guiding principles set forth by the IOM, the QIO Program assists providers in transforming health care to make it safe, effective, patient-centered, timely, efficient, and equitable.

In its proposed 9th scope of work, the QIO Program has identified coordination of care across settings as a priority. This draft document has not yet been finalized, but it appears that the program is at least considering quality indicators that go beyond individual settings (hospital, physician practice, nursing home, etc.) and instead focusing on indicators of quality that cross health care settings.

In the view of the Foundation, the four team care models developed with Foundation funding are poised to meet the growing demand for improved, cost-efficient care of Medicare beneficiaries with chronic illnesses.

The Foundation is proud of the role it has played in advancing improved care for older adults. It remains committed to working at the practice level to ensure that older adults receive the best care possible.

back to www.jhartfound.org ›