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Team Care Models

The advantages of interdisciplinary team care for improving the lives of older adult patients with chronic illness have been clearly demonstrated. The challenge remains to reshape the health care system in ways that transfer the knowledge gained from early studies and programs of team care into everyday clinical practice. With support and guidance from the Hartford Foundation, the five grantees of the GIT-P initiative developed innovative models of team care. The Foundation encouraged each of the grantees to keep the end user in mind as they developed these models.

Five sites were chosen that represent different approaches to interdisciplinary team care for treatment of older patients with chronic illnesses. These grants recognized the diversity of settings in which older adults receive health care services.

  1. The Care Transitions model addresses the challenge of coordinating care when patients must move among health care settings (for example, going to a rehabilitation facility or home after a stay in the hospital).
  2. In the Care Management Plus model, the care manager is augmented by information technology systems to facilitate care coordination.
  3. The Senior Health and Wellness Clinic model is an out-patient, primary care clinic that teaches and reinforces team care among its multi-disciplinary practitioners to deliver ambulatory primary care to frail, vulnerable elders living in the community.
  4. Because many primary care physicians work in solo or small practices, the Virtual Integrated Practice model was developed to allow for the creation of interdisciplinary teams of practitioners working in different settings.
  5. In the Senior Resource Team model, an interdisciplinary consulting team (composed of a geriatrician, gerontological nurse practitioner, and pharmacist) is embedded in a primary care practice.

The developers of these interdisciplinary, coordinated team care models are leading the way toward a revolution in the care of the nation's older adult population. Four of these models (described below) produced compelling evidence for improved, cost-effective geriatric care and are being vigorously promoted and disseminated with support from the Foundation's Dissemination of GIT initiative. The fifth model, while not being actively disseminated, offered important lessons.
Next: Model 1: Care Transitions Improving Transitions Across Sites of Geriatric Care ›