Integrated Care: Teams, Training & Technology

From 2019-2025, with the belief that coordinated care offers more, and better-connected, resources to populations that historically have had fewer resources available to them, Archstone Foundation focused its grantmaking on efforts to ensure integrated, equitable care for older adults through team care, training, and technology.

Teams

Background: Integrated health and social service teams, with patients and families at the center, are critical to providing high-quality care. No health or social service professional has all the skills to meet all the needs of older adults and their caregivers. And so, it is essential to foster high-quality care that is not only integrated, accessible, and equitable – but also provided by interprofessional teams. Teams that are trained well, and keep the patient and family at their center, produce more equitable outcomes, reduce costs, and improve both patient and provider satisfaction.

Archstone Foundation had seen that well-trained teams that integrate social supportive services with health care delivered better care at a lower cost, such as the Programs of All-Inclusive Care for the Elderly (PACE), which provides comprehensive medical and social services to frail, community-dwelling older people through an interdisciplinary team of health professionals providing PACE participants with personalized and highly coordinated care.

We had also seen how team care can be financially viable, especially with Centers for Medicare and Medicaid Services (CMS) Collaborative Care and Care Management Codes, and through the Chronic Care Act expansion of benefits. The Foundation’s work in partnered Collaborative Care for depression, known as Care Partners, was built around the concept of high-quality team care.

Other previously funded projects that focused on a team-based model include Elder Abuse Forensic Centers with the use of multidisciplinary teams, the Alzheimer’s and Dementia Care program at UCLA, and the Community Aging in Place – Advancing Better Living for Elders (CAPABLE) model, which improves safety and independence in older adults living in the community.

Training

Background: Providing comprehensive, culturally competent, client-centered, collaborative, coordinated, connected, and compassionate care for older adults in California requires a team of health and social service providers. And training is required for those team members to collaborate and coordinate effectively. Professionals as well as paraprofessionals – including direct care workers, community health workers, promotores de salud, and care navigators – will not be able to provide all the benefits of inclusive and interdisciplinary care unless they learn more about each other, the teamwork processes, and the principles of client-centered care.

With training grants, the Foundation centered its grantmaking on training health care and social service providers on effective evidence-based team care models focused on improving teamwork and complex care skills for all team members. Examples include interdisciplinary and cross-sector team training, meeting the needs of newer team members who are filling gaps in traditional care, and enhancing geriatrics and gerontological expertise and skills more broadly.

Drawing on our emerging learning in models of team care, we also supported the translation of that knowledge into training programs for practitioners in health care and social services to provide better care. Because so much hope is pinned on the impact of new workers in care coordination and navigation (e.g., CHWs and promotores de salud), the Foundation maintained a strong focus on the preparation and support for their vital role in health and social care teams.

Technology

Background: Improving communication networks and information technology is central to bolstering coordinated care for older adults in California. The ability to send and receive patient records and other information quickly and securely is central to enhancing the health and well-being of patients with complex medical and social needs. Technology also has the power to remove barriers limiting collaboration among patients, family caregivers, health care providers, and service agencies.

Archstone Foundation supported efforts that demonstrated technology’s benefits to all stakeholders in the care process. We funded grants that promoted the adoption of technologies, that facilitated teamwork between health care and social services providers, and that empowered older adults and their families to direct their care.