Team Up for Health: Supporting Patients for Better Chronic Care

This is archived content; for historical reference only.

Health care organizations are shifting from a prescriptive model for chronic disease care — where doctors tell patients what to do and patients are left to figure out how to do it — toward a “shared care” model, in which patients and clinicians collaborate on an approach for managing health.

Providers are also realizing the value of patients’ perspectives in identifying areas of clinic operations where improvement is needed and helping to make medical care delivery truly patient-centered. This new model focuses on equipping patients with the skills, knowledge, and confidence to manage their own health. Teams, which include patients and families, work together to define steps that lead to better self-management of chronic conditions.

These concepts have been central to Team Up for Health, a 42-month, $3.2 million CHCF initiative that has helped a cohort of community clinics, public hospital clinics, and medical groups improve the delivery of care for people with chronic conditions before, during, and after the medical visit.

An initial six-month planning phase improved grantees’ understanding of their organizations’ strengths and opportunities related to chronic conditions management and patient- and family-centered care. Subsequently, six grantees were selected for the two-year implementation phase, which began in August 2009. An additional year of funding then helped these grantees to sustain and spread their improvement activities.

The grantees were:

  • Asian Health Services, Alameda County
  • Golden Valley Health Centers, Merced and Stanislaus Counties
  • Northeast Valley Health Corporation, Los Angeles County
  • Open Door Community Health Centers, Humboldt County
  • San Francisco General Hospital Family Health Center, San Francisco County
  • Sharp Rees-Stealy Medical Group, San Diego County

These organizations focused on improving self-management support for people with diabetes; some focused on additional conditions as well. Grantees employed a variety of techniques to focus on the needs of patients and their families.

As a result, grantees were able to:

  • Enhance provider and staff communication skills
  • Create new ways to engage patients and families in their care and in improving the clinical practice
  • Plan and test strategies to transform processes
  • Leverage community and online resources

Independent Project Evaluation

An external evaluation, conducted by White Mountain Research Associates, measured the impact of this initiative on patients and providers. The evaluation report is available under Document Downloads and includes an addendum with additional findings from the final year of funding.

Team Up for Health Website

To capture the experiences and knowledge gained by Team Up for Health grantees, a website was created (since taken down) that provides interviews with grantees, patients, and others, as well as tools and approaches to engage patients and families in their care and improve medical care as a whole.