• 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:

Moving the Model from Two Sites to 100

The Care Transitions model was initially tested in two health systems: Kaiser Permanente of Denver and Centura Health. Even after the demonstration project was completed, these institutions continue to utilize the Care Transitions Intervention. Efforts to disseminate the model to other institutions have resulted in 100 organizations adopting the model by the end of 2007.

In Denver, CO, Frank Yanni meets with his primary care physician, Alan Lazaroff, MD, at Centura Senior Life Center several weeks after being discharged from the hospital. Of the four team care models in the dissemination of GIT-P grant, the Care Transitions model is the most widely disseminated. One surprise for Dr. Coleman and his team has been the diversity of health care delivery systems that have adopted the model. In developing the model, the team felt that it was a natural fit for Medicare Advantage (Medicare Managed Care Plans). They have also partnered with hospitals and home care agencies.

One key to the Colorado team's success in disseminating their model lies in the groundwork laid from the beginning. "Early on we were encouraged to think about what the end adopters would need," says Dr. Coleman. As part of the initial grant, the Hartford Foundation had asked them to write a business plan, which proved to be pivotal to the success of the program. He and his team put together a panel of experts (the key decision makers from health plans, hospitals, nursing homes, and home care agencies), presented the model, and sought input from the outset. They received concrete suggestions, which were used to alter the model. These recommendations, combined with input from patients and families, allowed Dr. Coleman and his colleagues to create a model that was likely to be implemented.

"The Care Transitions program is attractive because it is a relatively low cost and relatively simple intervention that has the potential to produce a very good return on the investment, both in terms of clinical outcomes and financially."Alan Lazaroff, MD
Director of Geriatric Medicine,
Centura Senior Life Center
Denver, Colorado
Adopter of Care Transitions Intervention Dr. Coleman also emphasizes that widespread dissemination depends on influencing the health care environment to build demand for this and other models of team care. Traditionally, a new model of care is developed and tested and then marketed to the end user or adopter. Dr. Coleman advocates a different approach. He works to influence the delivery system to make effective team care, including improved transitions across sites of care, a requirement. For example, Dr. Coleman and his colleagues partnered with the consumer representatives to the Joint Commission, a national accrediting body for hospitals and other health settings. This ultimately led to changes in the requirements of the Joint Commission regarding how patients are moved across the health care system. A Joint Commission Resources publication, titled "Improving Hand-Off Communication," features the Care Transitions Intervention model.

"This is how we create an environment that identifies a need for innovation and then we present our model as the logical solution," says Dr. Coleman.

Other changes in health care policy also work to the advantage of dissemination of the Care Transitions Intervention model. For example, hospitals are now required to publicly report 30- day readmission rates. A program such as the Care Transitions Intervention, which has proven to reduce readmission rates, becomes even more desirable.

Dr. Coleman continues to foster awareness of the poor quality of many care transitions, their adverse consequences for elderly patients and the need for reform. He does this through specially convened meetings of national and regional health care leaders, briefings with federal officials and other regulatory bodies, publications, speeches, and the Care Transitions Program Web site (www.caretransitions.org). His efforts have paid off as there is now much more system-wide recognition of the importance of this problem and a willingness to address it.

The long-standing commitment of the Hartford Foundation to the creation and dissemination of the Care Transitions Intervention model has allowed the University of Colorado Health Sciences Center to raise over $2.5 million in support of the model from additional funders. Sources of funding have come from the following:

1. CMS (in partnership with the Colorado QIO)
2. Community Health Foundation of Western and Central NY
3. California Health Care Foundation
4. Robert Wood Johnson Foundation
5. Christus Health Care
6. National Institutes of Health
7. Aetna Foundation

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