How Two Plans Built Their Care Teams
The team approach is essential to disease management. However, the multidisciplinary team you recruit to implement your program depends on your patient population. Below are two very different care team models. Lovelace Health Systems in Albuquerque, NM, has developed a care team model to support disease management for chronically ill group health patients such as diabetics and asthmatics. The Commu-nity Medical Alliance in Boston is a Medicaid health maintenance organization providing capitated care for the severely disabled. (For more on these programs, see pp. 185 and 187.)
Community medical alliance care team:
- primary care physician;
- nurse practitioners as clinicians and case managers;
- social workers;
- physical therapists;
- full-time durable medical equipment coordinator.
The plan recently added a new member to its care team, notes Robert J. Master, MD, president and medical director of Community Medical Alliance. "We’ve added a hospital-based nurse to our team to monitor the care of our patients in the hospital. We needed someone on our team to be our eyes and ears and to ensure that our care plans don’t fall apart in the acute setting."
Lovelace care team:
- a two-physician team including one primary care physician and one specialist;
- disease-specific nurse case managers;
- health educator;
- data specialist;
- pharmacist;
- administrative support staff.
"We wanted to create teams that included all the tools necessary to enhance care for a particular disease across the entire continuum from prevention to assessment and treatment to aftercare and follow-up for acute episodes," says Margaret J. Gunter, PhD, vice president and executive director of the Lovelace Clinic Foundation, a health research institute affiliated with Lovelace Health Systems. For example, early in its disease management efforts Lovelace made sure it had enough disease-specific case managers to handle both high-risk and medium-risk patients, says Gunter. "The whole name of the game is to identify and address risk before the patient shows up at your door, and that’s the central role of case management in disease management."
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