• 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:

Senior Health and Wellness Clinic Model

As a central element of the Senior Health and Wellness Clinic model, the interdisciplinary team meets weekly to discuss high-risk, complex patients. At PeaceHealth in Eugene, OR, staff members contribute valuable information that enable the clinic's most frail and vulnerable to continue living in the community. Senior Health and Wellness Center patients had lower average Medicare charges than comparison groups-even though participants were older, more vulnerable and higher risk-driven by same or reduced utilization of outpatient, hospital, and emergency department services.

Managing Care of Older Patients in the Clinic by Fostering Team Care

One approach to interdisciplinary team care for older patients with chronic illness involves providing comprehensive specialized geriatric primary care services all in one setting. The PeaceHealth Oregon Region Center for Senior Health set up such a clinic. The Senior Health and Wellness Clinic came to the attention of the Foundation through their work in the Institute for Healthcare Improvement (IHI) Breakthrough Collaborative on Improving Care for People with Chronic Conditions. Their work was subsequently presented at an IHI Congress conference in October 1998. The Foundation was impressed with the Senior Health Wellness Clinic model and in 2000 awarded PeaceHealth a 63-month grant of $1,407,390 to measure the impact of their interdisciplinary team care approach. The project is led by Ronald D. Stock, Executive Medical Director, the Gerontology Institute, PeaceHealth Oregon Region, Center for Senior Health, Eugene, Oregon.

Ronald D. Stock, MD, MA
Principal Investigator,
Senior Health and Wellness Clinic
PeaceHealth, Eugene, Oregon

"An interdisciplinary, interdependent team provides the best health outcomes, especially for older patients with complex care needs," says Dr. Stock. However, simply placing a group of health professionals from different disciplines in the same room does not mean that they will function well as a team. Most medical professionals are not trained in team skills. Formalized training and ongoing support of team behaviors is required, as demonstrated by the work of the Hartford Foundation's Geriatric Interdisciplinary Team Training (GITT) initiative.

Because interdisciplinary team care is not routinely practiced, the team care model developed at PeaceHealth focuses on team development. The model was designed to be most applicable for large, multispecialty group practices. It was developed and tested at the PeaceHealth Senior Health and Wellness Center (SHWC).²³ The SHWC is an outpatient fee-for-service clinic affiliated with Sacred Heart Medical Center, PeaceHealth in Eugene, Oregon. The SHWC is staffed by geriatricians, nurse practitioners, a social worker, a dietician, a pharmacist, and other health professionals.

“An interdisciplinary, interdependent team provides the best health outcomes, especially for older patients with complex care needs.”Ronald D. Stock, MD, MA
Principal Investigator,
Senior Health and Wellness Clinic

The methods created by the SHWC project team improve health outcomes by fostering productive interactions between a prepared, proactive health care team and informed, activated patients and/or caregivers. To ensure the ongoing benefits of team care, the SHWC developed a tool to continuously measure team development.
Next: Senior Health and Wellness Center: Total Care Under One Roof ›
23- Stock RD, Reece D, Cesario L. Developing a comprehensive interdisciplinary senior healthcare practice. J Am Ger Soc. 2004;52:2128-2133.