Five Steps to Maintain a Successful Team

Regardless of the team structure and purpose, several important elements need attention for ongoing, successful team care. These elements are presented below in no particular order.

1. Promote patient satisfaction, quality of life, and self-management

  • Address patients’ concerns such as insurance coverage and billing, confidentiality, time spent waiting, accessibility of providers, and continuity of care to improve patient satisfaction.
  • Provide self-management education to equip patients with the knowledge and skills to actively participate in their care, make informed decisions, set collaborative goals, carry out daily management, evaluate treatment outcomes, and communicate effectively with the health care team.
  • Reassess and redefine collaborative goals and supportive care to sustain achievement of goals over time.

2. Promote a community support network
The support of family, friends, and the entire community can help people with diabetes sustain self-management practices and a positive outlook over time.

  • Assess community support and resources such as institutional funding and grants from community agencies, groups, or services. Grants or industry support for indigent programs may be available.
  • Determine available Medicare and other insurer payment for health care professional provider services (including diabetes patient education and nutrition counseling), equipment, and supplies.
  • Help people with diabetes develop a community support network that includes family, friends, support groups, the faith community, and needed services such as transportation.
  • Encourage community organizations to support routine physical activity and the concept of healthy foods for all to create an environment that can contribute to improved health outcomes and quality of life.

3. Maintain team coordination and communication

  • Develop clear procedures to facilitate timely coordination of all required services.
  • Consider using standard treatment algorithms.
  • Reassess periodically to ensure continuity of care and patient satisfaction.
  • Develop communication methods between team members and the patient such as team meetings, patient rounds, and journal clubs to promote cohesion and a common approach to patient care.
  • Set individual patient clinical targets for blood glucose and lipid values, A1C, blood pressure, and body weight, and behavioral targets for food intake and physical activity. These targets provide a common ground for discussion of management strategies, collaborative goals, and evaluation of treatment outcomes.
  • Develop and maintain consistent messages from all team members to enhance patient understanding and increase effective self-management behaviors.
  • Communicate and document pertinent information from team members, ideally via a computerized information system.
  • Encourage mutual respect between team members and the patient.

Referral reports from eye care, foot care, dental professionals, and others can be incorporated into the patient’s health record through computer-generated reports, medical record notes, and personal and telephone contact.

4. Provide follow-up
Ongoing patient follow-up and regular scheduled visits for diabetes education, support, management, and preventive care are important to team success. A system to monitor and recall individuals for treatment and appointments, planned visits, and ongoing collaborative goal setting will facilitate the provision of these services.

  • Essential preventive services include foot examinations; screening for microalbuminuria, visual acuity, and glaucoma; retinal eye examinations; and oral screening and preventive dental care.
  • Follow-up care can be in the form of return face-to-face visits or interaction with other team members and community partners as well as telephone interviews and fax or email correspondence. Sending patients reminders and questionnaires encourages appointment keeping.
  • Arranging for patients to send self-monitored data and to receive phone counseling and ongoing therapeutic management can reduce the need for multiple clinic or office visits, prevent adverse events, and increase access to care for patients in medically underserved locations.1, 2, 3

5. Use health information technology
Secure computerized clinical information systems can

  • identify patients with diabetes, centralize their data and laboratory values, suggest a change in medication dosage, and enable timely referrals to other providers or specialists
  • automatically remind the team to conduct self-management education, provide preventive services, and schedule follow-up visits
  • help monitor quality of care by pooling medical record audit findings and comparing them with baseline measures or values attained in other practice settings
  • collect and report outcomes



This content is provided as a service of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), part of the National Institutes of Health. The NIDDK translates and disseminates research findings through its clearinghouses and education programs to increase knowledge and understanding about health and disease among patients, health professionals, and the public. Content produced by the NIDDK is carefully reviewed by NIDDK scientists and other experts.