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Designing Healthcare Systems That Work for People With Chronic Illnesses and Disabilities

Care Coordination

Wisconsin Partnership Model


Steve J. Landkamer, Project Manager, Wisconsin Partnership Program, State of Wisconsin Department of Health and Family Services, Madison, WI.

Jeanne Prochnow R.N., M.S.N., Director of Program Development, Community Care for the Elderly, Milwaukee, WI.

The Wisconsin Partnership Program (WPP) is a comprehensive program for Medicaid beneficiaries who are elderly or disabled and meet the State's nursing home criteria. Designed to eliminate fragmentation and promote prevention, the WPP integrates health and long-term support services, and includes home and community-based services (HCBS), physician services, and all other medical care. Members in this voluntary program are allowed to retain their primary care physicians (PCPs). Approximately 700 individuals are enrolled.

At the heart of the WPP is the use of interdisciplinary care coordination teams, featuring nurse practitioners (NPs), registered nurses (RNs) , and social service coordinators, as well as PCPs, natural supports, and appropriate specialists. The member is the central figure of the care team and has the right to refuse certain aspects of care; each document related to the care plan includes space to list the client's wishes for the particular area.

The nurse practitioner (NP) is both a substitute and supplement to the PCP, serving as primary liaison between the team, the member, and the PCP. The NP's tasks include:

  • Evaluating history and current medical status (periodically).
  • Evaluating episodic illnesses.
  • Taking the lead during transitions (e.g., hospitalizations, nursing home stays, and subacute care settings).
  • Ordering services.

The RN's tasks include:

  • Conducting assessments.
  • Providing skilled nursing services.
  • In conjunction with the NP, providing health education to members.

The social service coordinator's tasks include:

  • Conducting psycho-social/economic assessments.
  • Assisting members in gaining eligibility for appropriate programs.
  • Providing housing information.
  • Providing ongoing coordination of psycho-social services.
  • Assisting in crises.

The WPP operates through contracts with four community-based organizations that receive Medicaid and Medicare capitation payments. Community Care Organization (CCO) serves older adults in Milwaukee County; approximately 150 WPP members are enrolled. Most services—including primary care, some urgent care services, long-term care, and community-based social services—are provided in the member's home. CCO also has its own transportation system and contracted transportation services to enable members to receive needed services outside the home.

CCO has four interdisciplinary care coordination teams. Two are located with PACE (Program of All-inclusive Care for the Elderly) teams, although they operate independently of PACE; one is located in a housing complex serving low-income seniors, and one is located in a dementia day center within a hospital. Teams include NPs, RNs, social workers, PCPs, personal care workers, medical assistants, rehabilitative professionals, and facilitators.

Ms. Prochnow noted that using facilitators significantly increased the effectiveness of the teams. Teams meet daily or every other day for shared case management and service coordination; a member of the team reports back to the member on each meeting.

Attributes of individuals who are effective team members include:

  • Flexibility.
  • Creativity.
  • Assertiveness.
  • Team players.
  • Good communicators.
  • "Renegade" spirit (here Ms. Prochnow asserted that many solutions are simple but untraditional).
  • Excellent discipline-specific skills.

Early utilization trends seen by CCO as a result of the WPP model include: a decrease in specialist visits, hospitalizations comparable to Wisconsin's PACE program, and pharmacy costs approximately 10 percent higher than PACE.


The Wisconsin Partnership Program: a brief summary. Madison (WI): Wisconsin Department of Health and Family Services, Office of Strategic Finance, Center for Delivery Systems Development; 1999 May.

Bowers B, Esmond S. Interdisciplinary team curriculum: providing integrated consumer centered care team. Madison (WI): University of Wisconsin-Madison, School of Nursing; 1999. For full report:

Bowers B, Esmond S, Holloway E. Creating an integrated consumer centered care. Madison (WI): University of Wisconsin-Madison, School of Nursing; 1999.

The Wisconsin Partnership Program: protocol manual, part 1. Madison (WI): Wisconsin Department of Health and Family Services; 1999 Jul.

Bodenheimer T. Long-term care for the frail elderly people—the On Lok model. N Engl J Med 1999 Oct;341(17):1324-8.

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