Living with a chronic condition, something that takes a team of medical professionals to treat and assist with, is a challenge. Managing medications, appointments, diet, therapies, along with the general business of living, and maybe working, makes for a complex life. Most of us know someone with such a condition. Or, more likely, we don’t realize a friend or relative has a problem because it is well managed, they have a team and support network and it’s invisible.
But, if you don’t have a team, family, support and are not part of a managed medical care program via insurance, then it’s up to you to weave together the help you need. If you are alone, elderly or disabled, trying to tap into the myriad and ever-shifting services to help you stay out of the hospital or nursing home, can be easily overwhelming.
That’s one of the reasons TEAM San Diego was formed. San Diego County’s Aging & Independence Services saw how the systems of care in San Diego were in silos. Patients were confused and lacked information on how to coordinate their care. Doctors and social workers had no centralized means of communicating about a patient; even if the desire to coordinate was there, the ability was haphazard a best.
TEAM San Diego trains doctors, nurses, social workers, in home support services, and other professional care givers on how they can work across their disciplines and healthcare silos to coordinate the care of a common patient they may share. Part of the training is a practical session where “virtual teams” are created. These teams learn how by using the county’s free Aging & Independence Services Network of Care website, they, along with the patient, can track medications, treatments, therapies etc.
Minimizing hospitalizations and nursing home admissions has a huge impact on County budgets, but the greater impact is keeping the individual as self-sufficient and healthy as possible and creating a network of support. TEAM San Diego has come up with a way to create such a virtual network, and its success is why it was deserving of a 2010 CSAC Challenge Award.
CSAC Challenge Award Video for TEAM SAN DIEGO
Improving Chronic Care by Improving Care Coordination
TEAM SAN DIEGO Online Modules for Web-Based Learning include:
Teaming → Improved provider/patient communication and information-sharing among the health and social service team
Care Coordination → Prevent problems arising from multiple providers, treatments, and medications
Patient Empowerment → Encourage patients and caregivers to participate in decision-making, goal setting, and action planning
Resources → Find resources for problems specific to the San Diego chronic care community