CELEBRATING THIRTY YEARS OF AGING
AND HEALTH 2012 ANNUAL REPORT
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PROMOTE INTERDISCIPLINARY TEAM CARE

1983

Geriatric Interdisciplinary Teams in Practice

2001-2006 Following on the weak reception in health professions education of the Geriatric Interdisciplinary Team Training initiative, the Foundation sought to bolster the evidence for the clinical benefits of team care.

With $7.2 million, the Hartford Foundation created the Geriatric Interdisciplinary Teams in Practice (GIT-P) initiative to support the creation and testing of five new models of team care in diverse practice settings. In 2005, the Foundation awarded a grant to the University of Colorado Health Sciences Center to lead the effort to promote wider adoption of four of these models. Ultimately, two of the models that proved to have the most market potential received individual grants for even more widespread dissemination.

Care Transitions
The Care Transitions model, spearheaded by Eric A. Coleman, MD, MPH, University of Colorado Health Sciences Center, addresses the challenge of coordinating care for older hospitalized adults at risk for complications or rehospitalization. Patients with complex care needs and family caregivers work with a transition coach and learn self-management skills that make their transition from hospital to home safer (www.caretransitions.org).

The program was shown to be highly effective and to reduce hospital readmissions. It was supported with additional funding from the Robert Wood Johnson Foundation, California HealthCare Foundation, the Gordon and Betty Moore Foundation, Health Foundation for Western and Central New York, the Grotta Fund, the NIH and others. In 2008, the Hartford Foundation provided a grant of $1.1 million for further dissemination of the model, which was renewed in 2012.

The Care Transitions model has been adopted by more than 750 health care systems in over 40 states, and the numbers are growing. A confluence of national health policy initiatives has resulted in new financial incentives that enhance dissemination efforts. The Affordable Care Act contains a provision that allocates $500 million to foster partnerships between community-based organizations and hospitals, which can be accomplished by adopting the Care Transitions Intervention and other evidence-based programs.

Care Transitions and other Hartford-funded models have raised national awareness about the dangers for older adults as they transition between health care settings and providers.

(Above ) The Care Transitions Model. We need to fix the broken health care system where providers don’t talk to each other. But in the meantime, we need to support patients and families in their self-management role.” Eric A. Coleman, MD, MPH
Professor of Medicine
Division of Health Care Policy and Research
University of Colorado, Denver

Care Management Plus
Older adults with complex health care needs often see several physicians and other health care providers. These clinicians often do not communicate effectively with one another, which can lead to unnecessary health problems and more frequent hospitalizations.

To address this, Paul D. Clayton, PhD, and Laurie Burns, PTMS, at Intermountain Health Care in Salt Lake City, UT, created the Care Management Plus model. It has two main components: the introduction of a care manager (a nurse or social worker) and use of an electronic information technology system (www.caremanagementplus.org).

The model was shown to both improve quality of care and reduce costs. In 2007, the Foundation provided a grant to disseminate the model. By then, David A. Dorr, MD, MS, at Oregon Health & Science University, and Cherie Brunker, MD, at Intermountain Health Care, had assumed leadership of the project.

Adoption of the Care Management Plus model exceeded expectations. It has been implemented in 173 primary practice settings, and over 335 practitioners have been trained in the approach. An estimated 153,000 older adults (and 500,000 patients in total) have been served.

About $26 million in external funding has been obtained for the program from the Agency for Healthcare Research and Quality, the Gordon and Betty Moore Foundation, and others.

My job is to do all the things that a care manager does—screen, assess, plan, coordinate, and monitor. But I also treat the whole patient. For example, a patient might be referred to me for diabetes, but the patient is depressed. We can’t work on the diabetes until the depression is addressed. My job is to find out what’s causing the patient to have a difficult time managing his or her illness. Most patients want to be well. They just may not know how.” Ann Larsen, RN, CDE
Care Manager
Intermountain Healthcare
Medical Group
(Below) Care Management Plus Model. (Above, left) David A. Dorr, MD, MS, Associate Professor, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University.

(Above, right) Cherie P. Brunker, MD, Associate Professor, Geriatric Division, Intermountain Healthcare. Drs. Dorr and Brunker were co-leaders of the Foundation’s grant to test and spread the Care Management Plus model.
(Above) Senior Health and Wellness Clinic Model

Senior Health and Wellness Clinic
The PeaceHealth Oregon Region Center for Senior Health set up a clinic to provide comprehensive geriatric primary care services all in one setting. With a grant from the Hartford Foundation, PeaceHealth measured the impact of their interdisciplinary team care approach, a project led by Ronald D. Stock, MD, MA, Executive Medical Director of the Gerontology Institute at PeaceHealth Oregon Region, Center for Senior Health.

(Above) Virtual Integrated Practice Model

Virtual Integrated Practice
Primary care practices in rural settings often lack the capability to offer multidisciplinary team care. With the Virtual Integrated Practice (VIP) model, developed by Steven K. Rothschild, MD, Associate Professor of Family Medicine at Rush University Medical Center in Chicago and his colleagues, the primary care team identifies practitioners in nearby pharmacies, health care settings or community organizations and develops working relationships among them, communicating often through electronic means.

Senior Resource Team
Most older adults receive health care from primary care physicians who are not specialists in geriatrics. To address this, Edward H. Wagner, MD, MPH, and his colleagues at Group Health Cooperative Puget Sound created the Senior Resource Team model, in which an interdisciplinary geriatric consulting team is embedded in a primary care practice.

When this intervention was tested it did not result in better patient outcomes than the control group. Therefore, this model was not included in the dissemination phase of Geriatric Interdisciplinary Teams in Practice.

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