• 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:

Care Transitions Model:

A Transition Coach Makes Recovery from Surgery Faster, Easier

When Frank Yanni, 69, a participant in the Care Transitions Intervention program, noticed that the pain he was experiencing weeks after surgery for a staph infection of the spinal cord was not only not getting better but was getting worse, he knew to insist that it be looked into. A magnetic resonance imaging test revealed a postoperative infection that required a second surgery. "Had he let that go for even another week, he could have ended up in the ICU, septic and horribly sick," says Kathryn Botinelli, Frank's transition coach.

After coming home from spinal cord surgery, Frank Yanni and Transition Coach Kathryn Bottinelli, RN, review Mr. Yanni's upcoming appointments. As a former ICU nurse, Kathryn Bottinelli, RN, Transitions Coach, Centura Home Health, Denver, Colorado, has witnessed the devastating consequences when older adult patients fail to recognize early warning signs of an exacerbation of their illness and wind up critically ill. Now working as a Transitions Coach, Ms. Bottinelli is particularly interested in educating patients just discharged from the hospital about warning signs of complications that require early attention before a crisis occurs.

Ms. Botinelli began working with Frank and his wife Beatrice in August 2007. She first met the Yannis in the hospital when Frank was preparing to go home. The first surgery for the infection had left Frank in pain, for which he needed potent medications. Ms. Botinelli focused much of her work with the Yannis on pain control issues. Frank relied heavily on his wife to keep track of his medication schedule. "Our little purple book [the Personal Health Record] has been a great help to us," says Beatrice. "I can keep track of all his medications." Because Frank's medications were changed frequently, Ms. Botinelli worked closely with the couple on medication reconciliation.

(Below) The Personal Health Record provides Mr. Yanni and his wife Beatrice with an easy reference for medications information, post-hospital care needs, and space to log questions for the next time they visit the doctor. Ms. Botinelli also helped Frank with goal setting. He set as his goals being free from pain and being able to walk unaided. After the second surgery, Frank began to feel markedly better. The pain was diminishing and he was able to start physical therapy, including water aerobics, to regain mobility. He is steadily getting better and is optimistic that he will achieve his goals.

Having the opportunity to work with a Transitions Coach meant a lot to the Yannis. "Kathryn has been a great help to us," says Beatrice. "Working with her was very rewarding for me," adds Frank.

Ms. Botinelli also derives great satisfaction from working with the Yannis and other patients and family caregivers as their coach. She sees patients who are able to maintain their independence largely because they have access to the tools provided by the program, such as the Personal Health Record where they can read about red flags for their condition, write down the content of conversations with their coach and health care providers, and keep track of medications. This can be especially helpful for patients experiencing memory difficulties.

"With the Personal Health Record, patients feel more intelligent talking to the doctor," says Ms. Botinelli. And it helps the physician, especially for patients seeing multiple health care providers at different sites. "The patient feels more like a member of the team and the doctor talks to the patient with more respect, which motivates the patient to be more active in his or her own heath care," she adds, "and the patients heal quicker."

Next: Model 2: Care Management Plus ›