San Diego Long Term Care Integration Project Planning Committee Meeting September 12, 2007

SD LTCIP Stakeholder Vision n 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 n 84 year old woman lives alone n CHF, HTN, diabetes, hearing and vision loss, IADL dependencies n 16 medications by 6 MDs n Medicare and Medi-Cal beneficiary n Only child lives in Chicago

Journal of the American Geriatrics Society, Feb In-Home Services Day Health Care Acute Hospital Transit Skilled Nursing Facility Medical Specialty Meals Service Primary Care MRS. C. Ideal System Mrs. C & Care Manager

Physician Strategy Update n Implementation Plan for continued funding n 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 n Convene Advisory Committee to describe, support and assist in curriculum development n Develop cross-continuum team care protocol to guide the practical application of team skills in care management n Refine and finalize 8 hour online program and the six-hour classroom curriculum and delivery to community

Outcomes n Development of curriculum that encourages primary care providers to practice team care strategies on behalf of patients needing both medical and social supports n 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 n At least 80% of trainees report improved coordination across providers and settings three months post training. n At least 50% of participating chronic care patients report improved care; know how to better manage care for themselves n 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

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