• 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:

Virtual Integrated Practice Model:

Building Community Capacity

Dr. Rothschild and the group at Rush are using funds from the dissemination of GIT-P grant to develop materials to aid in the dissemination of the model to primary care practices. They have developed a VIP handbook and a Web site (www.rush.edu/professionals/vip/). They are also creating a train the trainer program. While discussions are underway with several health organizations and health insurance plans about adoption of the model, some organizations have already incorporated aspects of the model in their own team care projects.

As he began developing a pilot program in San Diego County for a coordinated, low-cost team approach to chronic illness care, Mark Meiners, PhD, George Mason University professor of health policy, learned of the VIP model and contacted Dr. Rothschild. When he first wrote the grant for the program, called "Team San Diego," Dr. Meiners used the term "virtual teaming," not knowing at the time that the idea of virtual teams was already being applied to the care of chronically ill patients. “Virtual team care introduces formality to things that are happening but in a haphazard and unsystematic way. By formalizing the team, chances of improving care are increased significantly.”Mark Meiners, PhD
Professor of Health Policy
George Mason University Fairfax, Virginia and National Program Director Medicare/Medicaid Integration Program, sponsored by the Robert Wood Johnson Foundation

Dr. Rothschild shared the VIP materials with Dr. Meiners, which he is now using to help develop the training, delivery, and evaluation methods for the Team San Diego project. "Virtual team care introduces formality to things that are happening but in a haphazard way," says Dr. Meiners. "By formalizing it the chances of improving care are increased significantly."

Dr. Rothschild and the group at Rush are also overseeing curriculum development as part of a broad initiative to expand the availability of Programs of All-Inclusive Care for the Elderly (PACE) across the United States. PACE, which has been supported by the Foundation since its earliest days, makes it possible for older adults to avoid nursing home placement and receive coordinated medical and social services, enabling them to age in their communities. It is a comprehensive, integrated health care plus financing model. The VIP team will build an on-line curriculum for Rural PACE. The National PACE Association has expressed interest in using the curriculum for urban settings as well.

(Above) Social worker, Robyn L. Golden, LCSW, with patient.
(Below) Catherine Catrambone, PhD, RN, explaining peak flow monitoring for asthma management. Other organizations that have consulted with the VIP team include Blue Cross of Illinois, Chicago Department on Aging (CDC Hispanic Elders Initiative), Chicago Department of Public Health, and the Illinois Department on Aging.

Validation from the Hartford effort was very important for co-investigators Robyn Golden and Stan Lapidos in their successful application to the Retirement Research Foundation. Awarded $203,234 over three years in 2006, project BRIGHTEN expands on the virtual team model to improve the identification and treatment of depression in primary care settings. Equally important has been the role of the Foundation in opening doors. The Hartford "imprimatur" is recognized for its high standards in quality care of older adults. As the team at Rush talks to physicians, hospitals, and professional societies, the John A. Hartford Foundation has been an important door opener.
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