• 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:

The National Search for Quality Health Care Finds Care Management Plus

The positive results of the Care Management Plus model have caused many primary care clinics, health care plans, health systems, and Medicare to take notice. Through the diligent work of Dr. Dorr, Dr. Brunker, and their colleagues, with support and funding from the Hartford Foundation's dissemination of GIT-P initiative, the Care Management Plus model has been implemented in over 30 health care sites across the country and the number is growing.

The first step in moving innovation to practice requires identifying like-minded people who are looking for ways to transform health care to improve quality and increase efficiency. Dr. Dorr makes presentations at local and national conferences to generate interest and several organizations have been led to the model through the Web site (www.caremanagementplus.org).

An early relationship with one of Medicare's quality improvement organizations (QIOs) gave the model important recognition and an early boost in dissemination.

At the time the Care Management Plus model was under development, the team at Intermountain Healthcare was working with a Medicare initiative called Doctor's Office Quality - Information Technology (DOQ-IT) to obtain Medicare data for analysis. Through the DOQ-IT project, Medicare supports the effective use of information technology by physicians' offices to improve quality and safety for Medicare beneficiaries. It soon became evident that there was a natural fit between the missions of the DOQ-IT and the Care Management Plus team care model.

“Care Management Plus has brought us together as a practice and provided the structure for caring for the most challenging patients.” Albert DiPiero, MD
Assistant Professor of Medicine,
Oregon Health & Science University
Adopter of the Care Management Plus model

To facilitate adoption of the Care Management Plus model, Dr. Dorr and his associates developed a training program. They also disseminate the information technology components (for example, the Care Management Tracking database) and provide expertise to help clinics successfully adopt these components. For the first training in September 2006, the DOQ-IT recruited six clinics from around the state of Utah to participate. This was soon followed by a presentation of the Care Management Plus model at the national conference of Quality Improvement Organizations (QIO). A subsequent article about the Care Management Plus model published in Quality Insight, the official journal of the QIOs, propelled the model to national attention. As a result, several clinics contacted Dr. Dorr's group to receive training in implementation of the model.

Adoption of Care Management Plus requires primary care clinics to make a substantial investment: hiring and training care managers, upgrading or acquiring information technology, and devoting the time and resources of other staff members to training and protocol implementation. Each clinic's investment is about $100,000 over the first year of the program, which should be recouped in increased productivity.

Given the need for this investment, an essential element of dissemination involves creating an environment for reimbursement and health policy that facilitates acceptance of the team care programs as cost-efficient. Toward this end, Dr. Dorr testified before the United States Senate Special Committee on Aging on May 9, 2007. Dr. Dorr stressed that care management programs can produce cost savings and also emphasized the need for reimbursement for the services offered by a care manager. U.S. Senator Blanche Lincoln and others, acknowledging the pressing need for change in the way the growing elderly population is cared for, had organized the session in support of a new bill that would pay for programs like Care Management Plus.

The Care Management Plus team also has a strong relationship with those working on the Donald W. Reynolds Foundation grant "Comprehensive Program to Strengthen Physicians Training in Geriatrics," awarded to the University of Utah with a subcontract to Intermountain Healthcare for $340,000 over four years. Dr. Dorr is also heavily involved in the Willamette Valley, Oregon, two-year, $600,000 Aligning Forces for Quality grant as a technical expert and primary care redesign expert.

Care Management Plus continues to successfully leverage the funding from the Hartford Foundation to help transform health care, pursue new areas of innovation, and develop partnerships to sustain these efforts. The 24 clinics that are fully implemented and the 18 more in process of implementation have committed millions of dollars toward the redesign of primary care for older adults. As further endorsement of the Hartford-funded effort, in 2007 the Agency for Healthcare Research and Quality (AHRQ) awarded $250,000 over two years for the Care Management Plus team to partner with the Oregon Rural Practice-based Research Network (ORPRN). Through this effort, six rural clinics will adopt the program and AHRQ will evaluate the business case and improvements in clinical outcomes.
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