Translational Research to Improve Medical and Social Service Integration for Aged and Disabled Patients

TEAM SAN DIEGO (TSD) is a community health education initiative designed to improve community care coordination for older, disables, and chronic care patients who need extensive medical and social services. This research project developed a concise online and in class curriculum to engage physicians, their office staff, and community-based health and social service providers in a training program to increase awareness of the target population's chronic care needs and available resources to serve those needs. It gives special emphasis to issues of consumer empowerment techniques and tools and the need for coordinating care across settings and providers with a virtual team approach. The project is targeted to San Diego County based medical and social service providers who serve chronically ill, aged, and persons with disabilities. Those who take the training are surveyed to determine outcomes related to community chronic care improvement.

The translational research project resulted in a new knowledge base and strategy leading to broader community understanding of chronic care management improvements. The local aging services agency improved its ability to use the Network of Care web tool for referral resources, patient education, personal health record-keeping. Social marketing efforts to encourage improved chronic care management are needed in communities around the County. A basic community health education curriculum for medical and social services providers that emphasize the topics covered in TEAM SAN DIEGO gives such efforts a useful framework to work toward chronic care management improvements.