Why Incubating More Teams Is Central to Expanding Coordinated Care

For the past year, Archstone Foundation has been working to refine and clarify the theory of change behind our strategic plan for better integrating health and social services. We are convinced that coordinated investments in three areas – promoting teams, enhancing training, and improving technology – will not only increase this care coordination but also yield fewer health disparities and more equitable outcomes.

One part of this work has been to synthesize our thinking about each of our Three T strategies in briefing papers we have named Calls to Partnership. They are our way of inviting potential grantees to consider how their work can further our effort to improve the health and well-being of older Californians and their caregivers.

This post, about our Call to Partnership for Promoting Teams, is the first in a series. Future posts will explore our strategies for enhancing training and improving technology.

What are teams?

No individual health care or social service professional has all the skills required to meet all the needs of older adults and their caregivers. We view the ideal care team as an interdisciplinary group of people who coordinate to provide both medical treatment and social services – working to eliminate traditional silos of care and placing the people they’re caring for, along with their family and friend caregivers, at the center.

People with the most serious illnesses or complex diagnoses often need the biggest and most collaborative teams, but all older Californians will benefit from a team’s coordinated approach to care.

Team members most often include physicians, nurses, social workers, and direct care workers, along with family members and friends. To address the growing diversity of older Californians, teams across the state are expanding to include lay health navigators and community health workers (known in Spanish-speaking communities as promotores or promotoras de salud) among others.

Teams as a Driver of Equitable Care

Teams must place older adults and their families at the center of care to ensure their preferences and goals are met. While this may seem like common sense, prioritizing the person being cared for does not always happen.

Older adults from communities of color and other marginalized groups have been systemically denied access to quality care and the damage has compounded during their lives, leading to poor health outcomes in later life. As the older population continues to expand and diversify, creating an expansive care team that includes both health care and social services providers will increase the chances they receive better and more informed care. This is especially true if both community health workers and lay care navigators are equipped with sufficient training and appropriate technology.

Team Care in Action

The UCLA Alzheimer’s and Dementia Care Program is a prime example of this. A dementia-care specialist is assigned to support and coordinate the comprehensive needs for each person living with dementia and their families. In coordination with a primary care provider, a personalized plan is developed and communicated to all members of the team. Teams of nurse practitioners and geriatric specialists, with the help of community-based resources, provide coordinated care. Regular patient monitoring ensures both ongoing and emerging needs are met, and training and support are provided to all caregivers.

This is unlike typical care, in which too many people with serious diagnoses must rely on themselves, or a single caregiver, to tackle the difficult task of navigating and managing care through an uncoordinated and siloed system.

Funding Principles and Opportunities for Partnership

We plan to support projects that can advance models of care teams, are structured to achieve more cost-effective and higher-quality care and demonstrate improved outcomes for older adults and their families – especially those from historically marginalized and under-served communities.

Given these commitments, future Teams grants may support proposals to:

• Adapt tested models to respond to the needs of diverse older adults and communities underserved by traditional care systems.
• Facilitate and establish connections between social services and healthcare systems.
• Promote community-based and clinical best practices that are comprehensive and utilize collaborative team care innovations.
• Provide additional resources to incorporate prior learnings and disseminate effective and affordable person-centered team care models.
• Increase organizational capacity for community-based organizations to partner with health care entities to bill for services provided.

By joining with a wide range of thought partners and grantees to turn our plans into programs and initiatives that increase care coordination and reduce health disparities, we will make measurable improvement to the health and well-being of older Californians and their caregivers.