CDC - Centers for Disease Control and Prevention  NIDDK - National Institute of Diabetes and Digestive and Kidney Diseases

NDEP is a partnership of the National Institutes of Health, the Centers for Disease Control and Prevention, and more than 200 public and private organizations.

What Makes a Team?

The patient is the central team member, since most diabetes care is carried out by the person with diabetes or his or her family. People with diabetes need to understand their roles as self-care managers and decision-makers to effectively work with members of their health care team. It is essential that a key person coordinate the team effort in a supportive, coaching-oriented way. [4] (See AAFP resource How to Solve Problems in Your Practice with a New Meeting Approach.)

Nurses, diabetes educators, dietitians, pharmacists, podia­trists, eye care providers, dental professionals, and other health care professionals can play important roles in the medical home model by working with primary care providers to collaboratively provide comprehensive diabetes care. Such care can include[3]:

  • management of blood glucose, lipids, and blood pressure
  • self-management education and support
  • weight management
  • smoking cessation counseling
  • diabetes complica­tion care and prevention

Collaborative teams vary according to[3]:

  • patient needs
  • patient load
  • organizational constraints
  • resources
  • clinical setting
  • geographic location
  • professional skills

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.

A constant subunit of a larger primary care team could be considered as a “teamlet” or little team. [5] A teamlet model proposes that a primary care clinician trains two office personnel such as a nurse and a medical assistant as “health coaches” who can proactively orchestrate chronic illness care and prevention, through pre-visit planning, in-visit closing of care gaps (i.e. by performing diabetes foot exams, providing immunizations and scheduling diabetes eye exams), and between visit outreach. Such health coaches may also provide self-management support to patients with chronic diseases such as diabetes. Each patient cared for by the teamlet would participate in an expanded visit with the clinician and the health coach and receive regular follow-up phone calls or emails from the coach.