The experience of one regional team within a large home health agency demonstrates that it is possible to provide comprehensive, patient-specific integrated care successfully under prospective pay and under managed care. This article describes the need-driven concept of a multidisciplinary care team model and follows its development over 3 years. It demonstrates that this approach can be fiscally successful with excellent outcomes for the patients, the clinicians, and the organization. The description takes the reader through the 3 years of development of this integrated care delivery model named for its originator.
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