U.S. Department of Health and Human Services

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.

Tools You Can Use

Redesigning the Health Care Team: Diabetes Prevention and Lifelong Management. Developed by the National Diabetes Education Program, this guide provides recommendations for how to implement multidisciplinary diabetes team care across clinical settings that are designed to improve patient outcomes and reduce cost through continuous, proactive, planned, patient-centered and population-based approaches to care. It includes eight case studies that demonstrate real-world team care in several different settings.

Primary Care Team Guide. Developed by the Primary Care Team: Learning from Effective Ambulatory Practices (LEAP), a national program of the Robert Wood Johnson Foundation, this guide presents practical advice, case studies, and tools from health care practices that have significantly improved care, efficiency, and satisfaction by transforming to a team-based approach.

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.

Effective team models of care may include:

Let the Evidence Guide You

Patel MS, Arron MJ, Sinsky TA, et al. Estimating the staffing infrastructure for a patient centered medical home. Am J Manag Care. 2013;19(6):509-16.

  • 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)

  • Get Credit!

    Creating Strong Team Culture. Developed by the American Medical Association as part of the STEPS Forward™ practice-based initiative, this module will help you to evaluate and improve team culture in your practice.

  • 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.

  • 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.

  • You Can Do It

    A Team-Building Model for Team-Based Care. Focusing on their strengths and borrowing concepts from family therapy helped bring this family medicine group together in pursuit of a common goal.
    Marlowe DP, Manusov EG, Teasley DJ. A team-building model for team-based care. Fam Pract Manag. 2012, 19(6):19-22.

    Building Teams in Primary Care: Lessons from 15 Case Studies. This two-part report examines approaches that 15 practices took to implement team-based models of care and lessons learned.

  • 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


1. Roman SH, Harris MI. Management of diabetes mellitus from a public health perspective. Endocrinol Metab Clin North Am. 1997;26(3):443-74.
2. Quickel KE. Managed care and diabetes, with special attention to the issue of who should provide care. Trans Am Clin Climatol Assoc. 1997;108:184-95.
3. Scanlon DP, Hollenbeak CS, Beich J, Dyer AM, Gabbay RA, Milstein A. Financial and clinical impact of team-based treatment for Medicaid enrollees with diabetes in a federally qualified health center. Diabetes Care. 2008;31(11):2160-5.
4. Huang ES, Zhang Q, Brown SE, Drum ML, Meltzer DO, Chin MH. The cost-effectiveness of improving diabetes care in U.S. federally qualified community health centers. Health Serv Res. 2007;42(6 Pt 1):2174-93.
5.Ray MD. Shared borders: Achieving the goals of interdisciplinary patient care. Am J Health Syst Pharm. 1998;55(13):1369-74.

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