San Diego Long Term Care Integration Project

Planning Committee MeetingSeptember 12, 2007

SD LTCIP Stakeholder Vision Develop “system” that:

– provides continuum of health, social and support services that “wrap around consumer” w/prevention & early intervention focus

– is consumer driven and responsive– expands access to/options for care– Engages MD as pivotal team member– Decreases fragmentation/duplication w/single point of entry,

single plan of care– Implements Olmstead Decision locally– Fairly compensates all providers w/rate structure developed

locally– Improves quality & is budget neutral– pools associated (categorical) funding– Maximizes federal and state funding

Mrs. C

84 year old woman lives alone CHF, HTN, diabetes, hearing and vision

loss, IADL dependencies 16 medications by 6 MDs Medicare and Medi-Cal beneficiary Only child lives in Chicago

Client Referral Patterns

Journal of the American Geriatrics Society, Feb. 1997

In-HomeServices

DayHealthCare

AcuteHospital

TransitSkilledNursingFacility

MedicalSpecialty

MealsService

PrimaryCare

MRS.C.

Ideal System

Mrs. C & Care

Manager

Physician Strategy Update Implementation Plan for continued funding Community Care Training/Team-Building

(“Team San Diego”)– Improve understanding aged and disabled

populations and needs– Foster collaboration across health and social

service providers– Improve resources for community-based

services, patient education material, communication with other providers, etc.

– Improve chronic care Management

TEAM SAN DIEGO Objectives

Convene Advisory Committee to describe, support and assist in curriculum development

Develop cross-continuum team care protocol to guide the practical application of team skills in care management

Refine and finalize 8 hour online program and the six-hour classroom curriculum and delivery to community

Outcomes Development of curriculum that encourages

primary care providers to practice team care strategies on behalf of patients needing both medical and social supports

Delivery of Team San Diego “business case” to at least 100 physicians. Delivery of TEAM SAN DIEGO 14 hour training to 200 physicians, office staff, and community providers

At least 80% of trainees report improved coordination across providers and settings three months post training.

At least 50% of participating chronic care patients report improved care; know how to better manage care for themselves

Disseminate findings and expand application of team care in San Diego

Team San Diego Online Modules Draft

1. Introductory Module – What is the problem and what are our solutions.

2. Problem Solving and Finding Resources within the Continuum of Care

3. Aging: Expectations and Challenges

4. Disabilities (physical and cognitive) and Behavioral Health Issues

5. Preferences, Environmental, Societal, and Cultural Impact on Health and Wellness

6. Supporting the Consumer as a Co-Producer of His/Her Own Health

7. Meeting the Needs of the Consumer through Teaming via Communication/Negotiation Skills

8. Patient Safety and Ethical Practice: Legal and Ethical Issues and Quality Improvement

For more information: Log onto website for background & info:

www.sdltcip.org

Call or e-mail:– evalyn.greb@sdcounty.ca.gov,

858-495-5428