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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: