At Rush, a team has been refining the VIP model for the past four years. The VIP’s objective is to improve chronic disease management for older people by deploying aninterdisciplinary team using communications technology.
The main challenges in primary care for VIP’s target patient population are:
- Multiple chronic problems
- Physical disability
- Functional impairment
- Economic stressors
The Holy Grail here is that when these patients are optimally-managed, VIP can identify missed opportunities for primary prevention and avoid eventual disability.
As the population ages, more chronic conditions ensue. Traditional
institutionally-based care in hospitals and nursing homes is based on
synchronous, face-to-face care. VIP disrupts that institutional model by embracing a team-based, asynchronous co-located model.
Clinicians on the patients’ team interact in the medical record and
enhance ongoing team communication about the patient’s progress.
The VIP team consists of a nurse, a social worker/case manager, a
physician, a pharmacist and a physical therapist. Here’s the
"co-located" part: They’re in different settings, and they relate to
the patient at different times. But they’re coordinated via information
technology — the electronic patient record.
One of the most important lessons the team learned in its four-year
study is that patients expect the professionals on care teams to
communicate with each other. This is typically not a streamlined,
efficient or effective process in traditional primary care.
Toolkits are available here for several health issues: diabetes, nutrition, urinary incontinence/overactive bladder.
The study is funded by the John Hartford Foundation of New York.
Jane’s Hot Points: The critical success factor with VIP is that
the patient is at the center of the process. The team emphasizes
self-management training in all interactions, and establishes
monitor-able goals throughout the encounters. Messages are triggered to
team members and to adjacent professionals as needed, which may include
a nutritionist, an ophthalmology, or a podiatrist, for example. With
the patient as an integral member of the virtual team, outcomes are
improved. It’s not about the technology per se — which clearly enables
this concept — it’s the process: the right caregiver at the right time
using the right technology.