• 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:

Important Role Foundations Play in Taking Risk and Learning from Failure

Edward H. Wagner, MD, MPH, Director, The W.A. MacColl Institute for Healthcare Innovation, Group Health Cooperative of Puget Sound, Seattle, Washington, is recognized internationally for his development of the Chronic Care Model, which encourages high-quality chronic disease management. Recognizing Dr. Wagner's work on developing and evaluating interventions for people with chronic illnesses, the Foundation awarded Group Health Cooperative of Puget Sound a five-year grant of $1,523,571 to develop the Senior Resource Team model of team care.

Foundations can offer funding to test creative solutions with the understanding that not all projects will produce viable interventions. In the case of the Senior Resource Team, when the intervention was tested it did not result in better patient outcomes than the control group. Therefore, this model was not included in the dissemination of the GIT-P grant.

Most older adults receive health care from primary care physicians who are not specialists in geriatrics. In the United States, there are on average 5.5 geriatricians per 10,000 persons aged 75²⁶ and the fill rate for the first year of geriatric medicine fellowship training programs is only about 70 percent.²⁷ This means that generalists working in primary care settings provide health care for large numbers of older patients, yet they often lack adequate training in the care of this population of patients. The result is the potential for suboptimal quality of care for older adults, who are at greatest risk for complex health problems and functional decline.

Edward H. Wagner, MD, MPH, and his colleagues at Group Health Cooperative of Puget Sound sought to address this issue by creating the Senior Resource Team model, in which an interdisciplinary geriatric consulting team is embedded in a primary care practice. In this model, the geriatric team consisted of a geriatrician, a gerontological nurse practitioner, and a pharmacist with specialized geriatric training (offsite but connected electronically). Dr. Wagner and his team reasoned that the close proximity of clinicians with geriatric expertise would encourage formal referrals as well as informal consultation, which would improve quality of care.

The Senior Resource Team provided ongoing geriatric education and support and focused on assessment and management of older adult outpatients (age 75 and older) at risk for disability, geriatric syndromes, and control of chronic diseases. The developers of the model hypothesized that this team approach would result in less functional decline and fewer hospitalizations for older patients. “We're contributing to the growing body of evidence that if you really want to improve important health measures in older patients you have to have a team with geriatric expertise actually manage the patients for a period of time, similar to the GEM units.”
Edward H. Wagner, MD, MPH
Director, The W.A. MacColl Institute
for Healthcare Innovation,
Group Health Cooperative of
Puget Sound, Seattle, WA To test this hypothesis, the team at Group Health Cooperative conducted a study involving two clinics and a total of 31 primary care providers. Patients aged 75 and older were randomly selected to receive care either with or without the Senior Resource Team model. After two years of the study, Dr. Wagner and his colleagues were not able to demonstrate a measurable benefit with the model. Overall, the primary care physicians viewed the intervention favorably and felt that their patients benefited from the direct care of the geriatric team and from the team's indirect influence on the primary care physician. However, referrals to the geriatric team were limited and there was no improvement in patients' functional ability, which was the main objective of the study.

“Even though the geriatric team was just down the hall, the kind of formal consultation that we had in mind didn't happen very often,” says Dr. Wagner. There was a subset of patients who were referred to the geriatric team, but these patients did no better than the control group. As a possible explanation, Dr. Wagner suggests that the geriatric teams in the Senior Resource Team model took a less intensive approach than a geriatric evaluation and management (GEM) unit, which has been shown to benefit patients. In a GEM unit, the geriatric team takes over care of the patient for a period of time. “Our teams didn't take over the care of patients,” says Dr. Wagner. “They complemented the primary care of patients and they tried to influence the primary care.”

Because the Senior Resource Team model was not able to demonstrate improvement in care of older adult patients, it has not been included in the GIT-P dissemination initiative. From the outset, the Foundation did not anticipate the success of all of the models. An important role of foundations is to take risks on untested interventions with the goal of learning from experience and thereby enhancing delivery of care to older adults. Even though the Senior Resource Team model did not produce the hoped for measurable improvements in patient outcomes, it did provide these important lessons.
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26- Warshaw GA, Bragg EJ. The training of geriatricians in the United States: three decades of progress. J Am Geriatr Soc. 2003;51:S338-345.
27- Warshaw GA, Bragg EJ, Shaull RW, et al. Geriatric medicine fellowship programs: a national study from the Association of Directors of Geriatric Academic Programs' Longitudinal Study of Training and Practice in Geriatric Medicine. J Am Geriatr Soc. 2003;51:1023-1030.