Integral role of the patient and family
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 program[19, 27] that is of high quality and is cost-neutral or cost-effective. The patient is the central team member, since most diabetes care is carried out by the person with diabetes or his or her family. Patients need to understand their roles as self-care managers and decision-makers to effectively work with members of their health care team. Family members assume most of this role for children and teens with diabetes.
Health care professionals
Teams usually include health care professionals with complementary skills who are committed to a common goal and approach. Some health care professionals may choose to become certified diabetes educators (CDEs). (See Appendix 2 for information on CDEs’ role.)
Team composition varies according to patients’ need, patient load, organizational constraints, resources, clinical setting, geographic location, and professional skills. It is essential that a key person coordinate the team effort. Non-traditional approaches to health care such as telehealth, shared medical appointments, and group education all expand access to team care.
A flexible plan helps meet specific needs
Not every team member needs to be involved in every patient’s care. A flexible plan helps determine the most effective team, as needs will change over time. For example
- A podiatrist may be involved in care for people with neuropathy, ulcerations, and other foot pathology. Podiatrists can provide comprehensive annual diabetes foot care examinations.
- A pharmacist may assist patients with multiple co-morbidities, or those requiring polypharmacy.
- Nurse educators, diabetes educators, and case managers can provide initial and ongoing diabetes self-management education, diabetes management support, and medication management services.
- Eye care professionals (optometrists and ophthalmologists) can provide comprehensive eye and vision care, including an annual dilated eye exam.
- A psychologist or social worker may be part of a team providing child and adolescent care.
- Dental professionals conduct oral examinations and provide oral health education in some community health centers.
- Clinical care teams can be augmented by the support and resources of school nurses, home health nurses, community health workers, and other community partners.
What can team care accomplish?
Many examples of team management for people with diabetes can be found in the scientific literature. A 2006 meta-analysis assessed the impact on glycemic control of 11 distinct strategies for quality improvement in adults with type 2 diabetes. Across 66 trials (50 randomized, three quazi-randomized, and 13 controlled before-after trials), two of 11 categories of quality improvement strategies were associated with reductions in A1C values of at least 0.5 percent. The two categories were team changes and case management.
- Effective team changes included the use of multidisciplinary teams, shared care between specialists and primary care physicians, or adding a new team member with an expanded professional role.
- Effective case management involved nurse or pharmacist case managers who followed physician-supervised algorithms to make medication adjustments.
Similar results were found in a group of low-income Latino patients who received supervised, nurse-directed care using detailed treatment algorithms.
Multidisciplinary teams are involved in pediatric care to effectively manage youths with diabetes.[34, 35] Team care contributed to the Steno-2 Study, a target-driven, long-term, intensified intervention that significantly reduced the risk of cardiovascular disease and microvascular events in adults with type 2 diabetes and microalbuminuria. Although team care may have played a role in the success of other large clinical trials, there is little discussion of its contribution in the literature.
Possible Diabetes Team Care Outcomes
Studies of diabetes team care in a variety of settings (see section 6) have shown improvements in one or more of the following
- glycemic, lipid, and blood pressure control
- patient follow-up
- patient satisfaction
- risk for diabetes complications
- quality of life
- health care costs
How to build and maintain effective teams
Six Team-building Steps presents important considerations for those creating or expanding team care, regardless of setting or program size: commitment of leadership; contributing team members; an identifiable patient population; adequate resources; a system for coordinated, continuous high-quality care; and an effectiveness evaluation plan.
Five Steps to Maintain a Successful Team presents elements that ongoing successful teams can promote: team coordination and communication; patient satisfaction, quality of life, and self-management; a community support network; patient follow-up; and the use of secure computerized clinical information systems.
Six Team-building Steps
These six steps identify important considerations for those creating or expanding team care, regardless of setting or program size.
1. Ensure the commitment of leadership
- Select well-respected clinicians to serve as catalysts to generate interest and support among colleagues.
- Meet with primary care providers and other potential team members, policy makers, and payment specialists such as business or office managers to obtain their support.
- Involve core team members early in organizational and clinical decision-making to gain their active participation.
- Demonstrate team care on a small scale, if necessary, to assess its feasibility, effectiveness, and impact.
2. Identify team members
- Invite potential team members to commit to participation.
- Clarify the roles of team members to resolve issues related to leadership and role overlap or redundancy in the care delivery process.
- Ensure mutual respect and a common vision.
3. Identify the patient population
- Initial assessment may be limited to general demographic characteristics and an estimate of the proportion of patients with type 1, type 2, and gestational diabetes.
- Further assessment could determine the presence of risk factors, number of patients with and without diabetes complications, severity of complications, the extent of comorbidities, use of health services, and delivery of preventive care.
- Once the diabetes patient population is known, the team might want to stratify the population into groups according to the intensity of services required.
- Newly diagnosed patients with limited diabetes complications might benefit from relatively low-cost preventive care focused on risk factor reduction and health promotion.
- Patients with diabetes complications or other comorbidities over the previous two-year period might need more intensive management with more extensive resources (see Appendix 1, Stratifying Team Care According to Patient Population Needs).
4. Assess resources
- Identify strengths and weaknesses in available resources (such as support staff, education materials, equipment, supplies, home care services, support groups, follow-up services, community resources). Ensure that adequate space, equipment, and supplies are available.
- Determine payment mechanisms for health care professional services, equipment, and supplies.
- Assemble user-friendly, current diabetes prevention and management protocols, tools, and education materials to ensure the delivery of current, culturally sensitive, and consistent care. These include standards of care, treatment guidelines, protocols and algorithms, patient education materials, flowcharts, standing orders, chart stickers, and other recording and reminder systems (see various resources in the Resources section).
5. Develop a system for coordinated, continuous, high-quality care
- Define the team philosophy, goals, and objectives.
- Develop a secure information system for patient identification, data collection, ongoing assessment, and monitoring the achievement of specific clinical performance measures such as hemoglobin A1C, blood pressure, and lipid target values, as well as patient satisfaction and quality-of-life indicators.
- Determine the structure and scope of the program or service. Teams can provide medical and clinical care; diabetes risk-reduction counseling; diabetes, lipid, and hypertension management; self-management education and medical nutrition therapy; psychosocial counseling; complications risk-factor reduction counseling; screening for complications; follow-up care; coordination of referrals to specialists; and access to supportive clinical and community resources.
- Base care on evidence-based guidelines adapted from widely accepted standards or practice guidelines to meet local conditions. (See various resources in the Resources section.) Develop a system that supports continuity of care through regular team meetings and ongoing documentation and communication of pertinent information among team members, ideally via a computerized information system.
- Structure a payment system for professional services (seeResources—AADE, Academy of Nutrtion and Dietetics, CMS).
6. Evaluate outcomes and adjust as necessary
Periodic process and outcome evaluations can help to improve team function and patient care.
- Databases with analytic reports, pooled medical record audit findings, utilization data (such as hospital length-of-stay, emergency room visits, and total dollars spent) can help evaluate outcomes of team care, determine future progress, and indicate team success in meeting quality measures (see Appendix 3, Quality Improvement Indicators for Diabetes Care).
- Patient satisfaction and quality-of-life interviews or questionnaires for patients can provide valuable feedback to the team and may influence the scope and manner of care provided.
- Document clinical, behavioral, and financial outcomes to show payers and other stakeholders the value of the services and return on investment.
- If desired, teams could seek funding and resources from a nearby university or other facility for an evaluation expert for advice or to conduct a more formal program evaluation.
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 (see CMS Resources).
- 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 (see various items in Resources).
- 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.
A multidisciplinary planning and documentation tool for the medical record 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.
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. (See NDEP Resources for a microvascular checklist.)
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.[41, 42, 43]
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