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Making Systems Changes for Better Diabetes CareMaking Systems Changes for Better Diabetes Care

Last updated Jan. 2006
In This Section
» Patient-Centered Care
 
- Dimensions
- Patient Education & Motivation
- Factors
- Education Examples
- How to
- Health Insurance Coverage
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»  Clinical Management
 
- Resources
- Complementary/Alternative Therapies
» Team Care
 
- Defining the Team
- Steps
- Advantages
» Community Partnerships
 
- Steps
- Education Examples
- Resources

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

  • clinical iconEnsure 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.

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Making Systems Changes for Better Diabetes Care Better Diabetes Care
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Better Diabetes Care
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Better Diabetes Care
Better Diabetes Care
Better Diabetes Care
Better Diabetes Care
Making Systems Changes for Better Diabetes Care Better Diabetes Care