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Executive Summary

This guide is designed to help health care professionals and health care organizations implement collaborative, multidisciplinary team care for adults and children with diabetes in a variety of settings. Collaborative teams that provide continuous, supportive, and effective care for people with diabetes throughout the course of their disease are a model for the prevention and management of chronic diseases. 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. 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.

Diabetes is a serious, common, and costly disease that affects 29.1 million people, or 9.3 percent of the U.S. population. About 90 to 95 percent of people with diabetes have type 2, which usually occurs in adults over age 45 but is increasingly occurring in younger age groups. Type 1 is usually diagnosed during childhood, although adults can also develop the disease. Some patients may have features of both type 1 and type 2 diabetes, which further complicates disease treatment and management. In addition, at least 86 million Americans aged 20 years or older have prediabetes, which places them at increased risk for cardiovascular disease and type 2 diabetes. The chronic complications of diabetes (cardiovascular disease, vision loss, kidney failure, nerve damage, and lower-extremity amputations) result in higher rates of disability, increased use of health care services, lost days from work, unemployment, decreased quality of life, and premature mortality. Acute complications can also result in lost days from school. The estimated diabetes cost in the United States in 2012 was $245 billion.

Despite its multi-system effects, it is possible to prevent or delay the onset of type 2 diabetes as well as to effectively manage both type 1 and type 2. Unequivocal evidence shows that early detection and early and aggressive ongoing therapeutic intervention significantly reduces the enormous human and economic toll from diabetes. To achieve the health benefits that modern science has made possible, the principal clinical features of diabetes—hyperglycemia, dyslipidemia, and hypertension—need to be prevented and managed within a system that provides continuous, proactive, planned, patient-centered, and population-based care. Primary care physicians, physician assistants, and nurse practitioners all play important roles in the delivery of primary care for people with chronic diseases in the United States. To reduce the risk of microvascular complications, this care needs to include regular assessment of the eyes, kidneys, teeth and mouth, and lower extremities in people with diabetes. System constraints, however, can make it difficult for primary care providers to carry out all of these essential elements of comprehensive diabetes care.

The challenge is to broaden delivery of care by expanding the health care team to include several types of health care professionals. Team care can minimize patients’ health risks by assessment, intervention, and surveillance to identify problems early and initiate timely treatment. Increased use of effective behavioral interventions to lower the risk of diabetes and treatments to improve glycemic control and cardiovascular risk profiles can prevent or delay progression to kidney failure, vision loss, nerve damage, lower-extremity amputation, and cardiovascular disease. Patients’ participation in treatment decisions, personal selection of behavioral goals, patient education and training, and active self-management can improve diabetes control. This in turn leads to increased patient satisfaction with care, better quality of life, improved health outcomes, and ultimately, lower health care costs.

Collaborative teams vary according to patients’ needs, patient load, organizational constraints, resources, clinical setting, geographic location, and professional skills. It is essential that a key person coordinate the team effort. The resources and support of community partners such as school nurses, community health workers, trained peer leaders, and others can augment clinical care teams. Non-traditional approaches to health care such as telehealth, shared medical appointments, and group education all expand access to team care and, if used effectively, can build team care practices.

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. It is difficult, however, to measure team care effects beyond these intermediate outcomes. Future evaluations of model medical home health care delivery programs will likely provide additional data about improved patient outcomes.

Effective team care requires

  • the commitment and support of organization leadership
  • the active participation of the patient and health care professional team members
  • ways to identify the patient population via an information tracking system
  • adequate resources
  • payment mechanisms for team care services
  • a coordinated communication system
  • documentation and evaluation of outcomes and adjustment of services as necessary

Teams can work effectively in many varied settings to improve the quality and effectiveness of diabetes care. Payment of services provided by health care professionals other than primary care providers and specialists—such as registered nurses, registered dietitians, and psychologists—although improving, often is inadequate. Examples in this guide from the peer-reviewed literature and case studies show the diversity and effectiveness of health care professional teams working with people with diabetes. These include

  • community-based primary care providers who involve a pharmacist and dietitian in implementing treatment algorithms, nurse and dietitian case managers, and educators who help to improve patients’ weight loss and A1C values
  • a nurse practitioner-physician team that manages patients with diabetes and hypertension
  • nurse and dietitian diabetes educators who help people with and at risk for diabetes achieve behavior-change goals leading to better clinical outcomes and who work with primary care physicians and staff to provide “diabetes day” individual and group patient appointments
  • school nurses who contribute to diabetes prevention and management in their students
  • a nurse, social worker, or psychologist who works closely with older patients, their primary care physician, and a consulting psychiatrist to treat depression
  • health care professionals who use telehealth to improve eye care, nutrition counseling, and diabetes self-management education
  • pharmacists who work with company employees who have diabetes and their physicians to improve clinical measures and lower health care costs
  • trained community-based fitness instructors who deliver group-based lifestyle interventions in YMCA settings to people at risk for diabetes to achieve increases in physical activity and significant weight loss
  • trained community health workers who bridge the gap between traditional health care teams to improve access to diabetes health care, complications assessment, and education in underserved communities
  • podiatrists and other health care professionals who help reduce lower-extremity amputation rates in foot care clinics
  • dental and eye care professionals who help prevent and manage diabetes complications

There is evidence that a team approach reduces risk factors for type 2 diabetes, can improve diabetes management, and can lower the risk for chronic diabetes complications. This evidence, in turn, shows that an opportunity exists for health care professionals and health organizations to improve the health of people with diabetes. It is important, however, that studies of team care interventions involving the skills of numerous health care professionals should continue to elucidate effective ways to implement team care to improve patients’ well-being and assess the costs involved.

February 2013​​​​​​