What We Want to Achieve Through Systems Changes

Team Care

An important challenge to effective delivery of health care is finding a way to meet the needs of patients with diabetes by broadening the care delivery opportunities available to primary care providers (physicians, nurse practitioners, and physician assistants) and other health care professionals, including nurses, dietitians, pharmacists, podiatrists, and mental health professionals. Team care meets this challenge by integrating the skills of different health care professionals with those of the patient and family members into a comprehensive lifetime diabetes management program. Short- and long-term benefits of diabetes team care include improved glycemic control, increased patient follow-up, higher patient satisfaction, lower risk for the complications of diabetes, improved quality of life, and decreased health costs.

The key function of a health care team is to provide continuous, supportive, and optimal care for people with diabetes throughout the course of their disease. For team care to succeed, the following elements must be in place:

• Commitment of policy makers (e.g., purchasers of health care, medical directors, benefits managers, chief executive officers) to establish and sustain an infrastructure supportive of team care.
• Reimbursement for the services of core team members proportional to their expertise and time involved in diabetes team care.
• Regular communication among team members and documentation of provided care.

Forming a team requires a planning group to do the following.

• Ensure the commitment of leadership.
• Gain support from care providers.
• Identify team members
• Identify the patient population.
• Stratify the patient population according to the intensity of services needed.
• Assess resources.
• Develop a system for coordinated,
  continuous, quality care.
• Evaluate outcomes and adjust services as necessary.
  

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