Last updated Jan. 2006
Note |
Team
composition can vary based on:
• patient need
• organizational structure
• resources
• professional skills available
|
|
What
We Want to Achieve Through Systems Changes
Team
Care: Steps to Implementing the Team Plan
- Ensure
the commitment of leadership.
The
first step requires an organization's key decision-makers
to commit to the implementation of multi-disciplinary team care
and the necessary resources and infrastructure to enable the team
to function. Once the commitment is made, a planning group can
carry out the following steps.
- Gain
support from care providers.
- Select
well-respected clinicians to serve as catalysts to generate
interest and support among colleagues.
- Obtain
the support of primary care providers and other potential
team members.
- 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 increase provider
comfort and adjustment to a new method of care, and to assess
its feasibility, effectiveness and impact.
- Identify
Team Members
-
Meet with potential team members, policy makers, and business
representatives such as clinic or office managers responsible
for reimbursement.
-
Clarify the roles of team members to resolve issues related
to leadership and role overlap or redundancy in the care delivery
process.
- Identify
the patient population
- Initial
assessment may be limited to general demographic characteristics
and an estimate for 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,
number receiving intensive insulin therapy, the extent of comorbidities, use of health
services, and delivery of preventive care.
-
Stratify the Patient Population
-
Once the diabetes patient population is known, the team may
want to stratify the population into groups according to the
intensity of services required. Patients at risk for diabetes
complications may benefit from relatively low-cost preventative
care focused on risk factor reduction and health promotion.
- Identifying
the patients who have diabetes complications,
frequent hospitalizations, intensive treatment programs,
or comorbidities
over a previous two-year period can help determine those who
will require more extensive resources.
- Assess
resources
- Identify
strengths and weaknesses in available resources (such as
health professionals, support staff, available education programs, education materials, equipment, supplies, home care services, support groups, specialty referral sources, follow-up services).
- Ensure
that adequate space, equipment, and supplies are available.
- Acquire
state-of-the art management protocols and education materials
to ensure the delivery of current, culturally sensitive and
consistent care.
- Assess
community support and resources such as institutional funding
and grants from community agencies, groups, or services.
-
Determine available reimbursement for provider services (including
education and nutrition), equipment, and supplies. Determine
availability of grants or industry support for indigent.
- Develop
a system for coordinated, continuous, quality care
- Define
the team philosophy, goals and objectives.
-
Develop a secure information system for patient identification,
data collection, and ongoing assessment.
- Determine
the structure and scope of the program or service. Teams can
provide diabetes, lipid, and hypertension
management; self management education and nutrition therapy;
psychosocial counseling; risk factor reduction; screening
for complications; follow up care; coordination of referrals
to specialists; and access to supportive clinical and community
resources.
- Base
care on locally accepted guidelines adapted
from widely accepted standards or practice guidelines to meet
local conditions. Click here to link to Clinical Recommendations in the Toolbox.
- 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 and/or reimbursement system for provider services.
- Develop
a system for monitoring the achievement of specific performance
measures such as use of hemoglobin A1c.
- Evaluate
outcomes and adjust as necessary.
- Plan
for regular service assessment and clinical and economic evaluation
of provider performance measures and patient outcomes and satisfaction.
-Return
to the Top-
-Return Home-
Continue to
Team Care:
Advantages |
|