• 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:

Measuring the Success of Care Management Plus

Dr. Cherie Brunker meets with patient John Walton and his wife Ruth. Care Management Plus's information systems have allowed the three of them to work together to control John's diabetes through a combination of exercise, changes in diet, and insulin regimen. This straightforward approach of integrating care managers into the primary care team and using information technology tools improves health and decreases complications for older adults. In initial research and testing of the model, people with diabetes had better control of their blood sugar levels and were more likely to be tested, which corresponded to 15 to 25 percent fewer long-term complications. This translates into significant cost savings and allows patients to live independently far longer. Seniors with diabetes had a 20 percent reduction in death and a 24 percent reduction in hospitalizations, saving Medicare up to $274,000 per clinic.^18,19,20

Dr. Cherie Brunker uses the Patient Worksheet, an information technology tool, to provide goal-directed evidence-based medical care for her patients. Benefits to practices are derived in several ways. For example, through the use of information technology systems, physicians can create a more efficient medical practice and can see more patients. A study by Dr. Dorr and colleagues demonstrated an 8 to 12 percent improvement in productivity of health care providers who actively send patients to a care manager versus those who do not.²¹ This translates to over $99,000 per clinic in additional revenue. With the increase in productivity and the right clinic environment, care manager services can be cost effective, even in Medicare fee-for-service. “We need to pay attention to preventing medical problems and preventing complications that can be avoided. The Care Management Plus program can help older adults, including healthy older adults, to maintain their health by focusing on prevention.”Cherie Brunker, MD
Co-Principal Investigator,
Care Management Plus
Intermountain Healthcare
LDS Hospital Division of Geriatrics

The benefits extend to the larger society as well, both in terms of health and dollars. For example, implementing the program in 60 clinics is estimated to prevent 259 hospitalizations per year and to eliminate 253 unnecessary deaths per year.²² Medicare will save approximately $9.1 million on reduced costs of the seniors treated.
Next: The National Search for Quality Health Care Finds Care Management Plus ›

18- Dorr DA, Wilcox A, Donnelly SM, Burns L, Clayton PD. Impact of generalist care managers on patients with diabetes. Health Serv Res. 2005;40(5 Pt 1):1400-1421.
19- Dorr D, Brunker C, Wilcox A, Burns L. Implementing protocols is not enough: the need for flexible, broad based care management in primary care. TRIPP conference; 2006 July 10-12; Washington, DC: AHRQ;2006.
20- Dorr DA, Wilcox A, Burns L, Brunker CP, Narus SP, Clayton PD. Implementing a multidisease chronic care model in primary care using people and technology. Dis Manag. 2006;9(1):1-15.
21- Dorr DA, Wilcox A. McConnell KJ, Burns L. Brunker CP. Productivity enhancement for primary care providers using multicondition care management. Am J Manag Care. 2007;13(1):22-28.
22- Dorr DA, Donnelly SM, Wilcox AB, Brunker CB, Burns L. Incorporating multidisease care management into primary care using people and technology. Academy Health, June 25-28, 2006, Seattle, WA.