What is a Team?

Team care integrates the skills of primary care providers and other health care professionals with those of the patient and family members into a comprehensive lifetime diabetes management program1,2 that is high quality and cost-neutral3 or cost-effective.4 Because most diabetes care is carried out by the person with diabetes or his or her family, the patient is the central team member.

Teams usually include health care professionals with complementary skills who are committed to a common goal and approach.5 Team composition varies according to patients’ needs, patient load, organizational constraints, resources, clinical setting, geographic location, and professional skills. Teams may be physically located together or virtually connected through integrated and coordinated care processes.

To be optimally effective, teams may choose to develop a multidisciplinary planning and documentation tool for the medical record, which could include treatment goals, personal patient goals, and disease management, including medications, medical nutrition therapy, self-management education, and referrals. Such a tool can help all team members to clarify responsibilities, coordinate care, and communicate the patient’s progress in a timely way.6

Effective team models of care may include:

  • Building multidisciplinary teams (e.g., adding new team members such as diabetes educators, registered dietitians, social workers, psychologists, or pharmacists)
  • Expanding the professional role of an existing team member within the primary care practice setting (e.g., training nurses as health coaches or care coordinators, training medical office assistants to conduct pre-visit screenings)
  • Establishing small teams or “teamlets” led by physicians who are supported by one or more health care professionals, such as an advanced practice nurses, registered nurses, licensed practice nurses, medical office assistants, or care coordinators, to improve case management. For more information about “teamlets” see The Visit: Time with the Physician which features a “teamlets” section.
  • Maintaining team coordination and communication. Read more about how to maintain a successful team.
  • Coordinating shared care between primary care providers and specialists (e.g., podiatrists, eye doctors, dentists, pharmacists, endocrinologists). For more information about shared care see Integrating Other Practitioners.
  • Expanding access to team care through non-traditional approaches to health care, such as telehealth, shared medical appointments, and group education.
  • Augmenting clinical care teams by linking to the resources and support of community partners such as school nurses, community health workers, trained peer leaders and others. For more information on partners in the community see Community Partnerships.

The benefits of diabetes team care include efficient patient education, improved glycemic control, increased patient follow-up, higher patient satisfaction, lower risk for the complications of diabetes, improved quality of life, reduced hospitalizations, and decreased health care costs.

Building and sustaining an effective patient-centered diabetes team requires:

  • Commitment and support from organization leadership
  • Active participation from the patient and health care professional team members
  • Ways to identify the patient population through health information systems
  • Adequate resources
  • Payment mechanisms for team care services
  • A coordinated communication system
  • Documentation and evaluation of outcomes and adjustment of services as necessary
  • Patient satisfaction, quality of life, and self-management