• 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:

Senior Health and Wellness Clinic Model:

Measuring the Success of Senior Health and Wellness Clinic

The SHWC model improves quality of care and reduces the number of medications that older patients take. Supported by the Foundation's grant, Dr. Stock and his colleagues conducted a study in which patients of the SHWC were compared to patients receiving care from primary care providers supported by a care manager and patients cared for in practices without a care manager. And the practice grew with implementation of the model.

Senior Health and Wellness Clinic team members meet with patient Christa St. George. Patients treated at the SWHC were more likely to receive vaccinations, were prescribed fewer medications, and were less likely to fall.

Patients treated at the SHWC were more likely to receive vaccinations. They were prescribed fewer medications (thus lowering the risk for dangerous interactions among drugs). Rates of falls were less in the SHWC model compared to the other models, especially for older female patients. Scores on tests for depression improved with the SHWC model, whereas scores worsened in the comparison groups. Physical function declined for more than 80 percent of participants in all the groups given aging over two years. However, the health-related quality of life (HRQL) remained unchanged for those in the SHWC model, while the participants in the other groups experienced a decline in HRQL that paralleled the decline in physical function.²⁴

Of note, average Medicare charges per participant were less in the SHWC group than the other two groups for all services. Despite evidence that the patients treated at the SHWC were older, more vulnerable, and at higher health risk than patients in the comparison groups, utilization of outpatient, hospital, and emergency department services were the same or less. Also, while caring for this population, the practice grew, adding staff and patients.
Next: Illustration: Senior Health and Wellness Clinic ›

“Working as a team is the only way to take care of a geriatric population.”Kathleen Chinn, FNP
Senior Health and Wellness Center
PeaceHealth Medical Group

24- Stock RD, Mahoney E, Reece D, Cesario L. Developing a senior healthcare practice using the chronic care model: effect on physical function and health related quality of life. J Am Ger Soc. 2008. Accepted for publication.