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San Diego Long Term Care Integration Project. Planning Committee Meeting September 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

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San diego long term care integration project

San Diego Long Term Care Integration Project

Planning Committee Meeting

September 12, 2007

Sd ltcip stakeholder vision
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
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

Ideal System












Mrs. C &



Journal of the American Geriatrics Society, Feb. 1997

Physician strategy update
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


  • 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
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
For more information:

  • Log onto website for background & info:

  • Call or e-mail:

    • [email protected],