• 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 Management Plus:

Description of the Model: Care Management Plus

The Intermountain Healthcare (Salt Lake City) Care Management Plus Team: Cherie Brunker, MD (front right), and her Primary Care Team (clockwise): Liz Garcia-Leavitt, LCSW (Care Manager), Vikie Durrant (Receptionist), Kip DeWeese, APRN, GNP (Nurse Practitioner), Mary Carpenter, LPN (Licensed Practical Nurse). The Team applies the Information Technology tools and works together with their patients and caregivers to provide efficient, high quality health care. In the Care Management Plus model, physicians in a primary care practice identify patients with complex care needs and refer them to a care manager. These patients with long-term chronic diseases require more education or more time to understand their medications or other aspects of their care. For example, they may need to learn about controlling their diabetes, they may be frail, or they may be at high risk for complications.

The care manager-in consultation with the patient, family, physicians, and other health care providers-assesses the patient's needs, creates a care plan, and acts as a catalyst to make sure the care plan occurs. Care managers help patients and caregivers to self-manage their disease and navigate the health care system. They provide links to community resources and ensure that patients receive the highest quality care. The care manager also can identify possible coexisting conditions, such as depression, or other barriers that may be preventing the patient from effectively managing their illness.

“My job is to do all the things that a care manger does-screen, assess, plan, coordinate, and monitor,” says Ann Larsen, RN, CDE, Care Manager, Intermountain Healthcare Medical Group, Roy, Utah. “But I also treat the whole patient. For example, a patient might be referred to me for diabetes, but the patient is depressed. We can't work on the diabetes until the depression is addressed. My job is to find out what's causing the patient to have a difficult time managing his or her illness. Most patients want to be well. They just may not know how.”

Care Management Plus provides a variety of printed and virtual tools to assist both doctors and older patients in managing complex health conditions. An electronic information system facilitates the work of the interdisciplinary team by incorporating protocols and reminders for optimal care of patients. For example, the Care Management Tracking database keeps track of tasks, such as following up with other clinicians, calling patients to check in with them, and assuring tests are ordered. It also keeps track of patient outcomes. A Patient Summary sheet contains pertinent health information. Electronic messaging systems help providers gain access to care plans, remind them about the best health care practices for the patient's condition, and facilitate communication among the health care team. The system also creates reports for ongoing assessment and administration of a care management program.

“Having these tools helps the clinic to be more efficient,” says Cherie Brunker, MD, co-principal investigator, Care Management Plus. “Before I see a patient, the system has identified lab work, such as liver function tests or other routine tests for a specific patient, and the office staff puts that in the queue to be ordered. It's done automatically.”

These freely available information technology tools were developed by Drs. Clayton and Wilcox at Intermountain Healthcare as part of the project supported by the Foundation. Care managers can use these tools to access disease-specific recommendations and reminders. This technology is specifically created for and by care managers and care teams that are responsible for the care of older adults.
Next Page › “Care managers augment what the doctor does. Physicians
feel better about the medicine that they practice and patients feel better about the care they have received. Overall, the outcome is better health.” Linda Leckman, MD
Chief Executive Officer,
Intermountain Medical Group Next: Illustration: Care Management Plus Model ›