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Team-Based Care

Objective of Section

To introduce concepts and models of team-based care and provide useful resources for integrating these elements into practice.

Key Concepts

  1. Collaborative teams that provide continuous, supportive, and effective care for people with diabetes throughout the course of their disease serve as a model for the prevention and management of chronic diseases.
  2. Well-implemented diabetes team care can be cost-effective and the preferred method of care delivery, particularly when services include health promotion and disease prevention in addition to intensive clinical management.
  3. Team care is a key component of health care reform initiatives that incorporate an integrated health care delivery system, especially those for chronic disease prevention and management.


Modern understanding of diabetes prevention and management advocates for the superiority of team-based care rooted in the primary care setting. High-functioning patient-centered teams work more efficiently and effectively to provide quality diabetes care and improve health outcomes.1,2,3,4,5 In addition, team-based approaches are central to meeting the “triple aim” of optimizing health system performance—better care, better health, and more cost-effective. In turn, a fourth important aim emerges: to improve provider experience by decreasing burden, increasing joy, and preventing burnout.

The Institute for Healthcare Improvement Triple Aim:

  • Improving the patient experience of care (including quality and satisfaction)
  • Improving the health of populations
  • Reducing the per capita cost of health care

The importance of team care is further highlighted by its inclusion in the Chronic Care Model and the Patient Centered Medical Home. The Chronic Care Model,6 which provides a framework for effective care of diabetes and other chronic diseases, incorporates team care as a vital component of delivery system design. The Patient Centered Medical Home model, which also includes team-based care, encourages a proactive approach to health promotion, disease prevention, and chronic disease management through the development of individualized care plans and effective health care team member communication and coordination of care.7

Let the Evidence Guide You

Transforming Primary Care: What Works and What’s Next

—This PowerPoint presentation (and associated CD) from Improving Chronic Illness Care further explains the rationale behind health care reform and introduces potential strategies and considerations for practices.

Although team-based care represents the future of diabetes and other chronic disease prevention and management in the United States, this approach is a distinct shift from the traditional delivery model of primary care. As such, transformation of practice and delivery system redesign are required to fully realize the potential of team-based care approaches. Practice transformation strategies, resources, and tools included in this section are designed to help primary care practices in developing team-based approaches that align with health care reform requirements.

Information systems are a critical component of successful team-based care, helping facilitate decision support, effective and efficient communication, and information sharing among providers and patients. They also serve as a valuable population management tool. Learn more about how information systems can support team-based care.


1. Wagner EH, Grothaus LC, Sandhu N, et al. Chronic care clinics for diabetes in primary care: A system-wide randomized trial. Diabetes Care. 2001;24(4):695-700.
2. Rubin RR, Peyrot M, Siminerio LM. Health care and patient-reported outcomes: Results of the cross-national Diabetes Attitudes, Wishes and Needs (DAWN) study. Diabetes Care. 2006;29(6):1249-55.
3.Funnell MM, Anderson RM. Changing office practice and health care systems to facilitate diabetes self-management. Curr Diab Rep. 2003;3(2):127-33.
4. Shojania KG, Ranji SR, McDonald KM, et al. Effects of quality improvement strategies for type 2 diabetes on glycemic control: A meta-regression analysis. JAMA. 2006;296(4):427-40.
5. Piatt GA, Orchard TJ, Emerson S, et al. Translating the chronic care model into the community: results from a randomized controlled trial of a multifaceted diabetes care intervention. Diabetes Care. 2006;29(4):811-7.
6. Wagner EH. Chronic disease management: What will it take to improve care for chronic illness? Eff Clin Pract. 1998;1(1):2-4.
7.Margolius D, Bodenheimer T: Transforming primary care: from past practice to the practice of the future. Health Aff (Millwood) 2010; 29(5): 779-84.

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