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

  2. 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

  3. 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

  4. Ideal System In-HomeServices PrimaryCare AcuteHospital MealsService MRS. C. DayHealthCare Transit Medical Specialty SkilledNursingFacility Mrs. C & Care Manager Journal of the American Geriatrics Society, Feb. 1997

  5. 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

  6. 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

  7. 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

  8. 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

  9. For more information: • Log onto website for background & info: • Call or e-mail: •, 858-495-5428