Team Management

Team management is a coordinated multidisciplinary approach. It is crucial to share information to develop and implement a patient's care plan, and to evaluate success. The composition of the team will vary depending on the setting. Typically, a physician, or advanced practice provider, initiates direction and supervises medical care. A nurse or nutritionist participates in assessments, and other disciplines are utilized as available. A more comprehensive team (health psychologist or behavioralist, social worker, podiatrist, pharmacist, etc.) may also be involved. The team usually consists of three or four healthcare providers with complementary skills who are committed to one common goal or approach (13) and includes a physician or other primary-care provider, a nurse and a dietitian, and it is recommended that at least one member is a Certified Diabetes Educator [(CDE) requiring the passing of an exam administered by the National Certification Board for Diabetes Education] (2). The team is multidimensional, with accountability as defined by their individual discipline's scope of practice. A multidisciplinary team offers a variety of skills, experience that contributes to a common purpose (13).

Primary care physicians often provide the majority of diabetes care, augmented and enhanced by other healthcare professionals and community partners and services. In the USA, a primary care practitioner, advanced nurse practitioner, or physician assistant often take on the coordinating care role. Nurse practitioners have been shown to produce similar clinical outcomes to physicians in a primary care setting (17). A primary care team consists of medical and educational managers. It is essential that a key individual coordinates the care effort between primary care providers, CDE, and other healthcare providers.

The diabetes control and complications trial (DCCT) was a large clinical trial of people with type 1 diabetes mellitus, and included medicine, nursing, nutrition, education, and counselling (18,19). The UK Prospective Diabetes Study (UKPDS), a clinical trial of people with type 2 diabetes, included teams of physicians, nurses, and dietitians (20). O'Connor summarizes primary care setting progress towards the goal of better diabetes care (21). Successful interventions need to utilize the strategy of:

■ Prioritize

Not every team member needs to be involved with every patient, but will be guided by the assessed needs, selected by age grouping of the person (from pediatric to geriatric); special needs (language, literacy, learning abilities, family interactions, etc.); level of information required (basic survival skills to advanced level); the intensity of management (meal planning to infusion pump); and availability. All these factors will influence the frequency of contact and amount of time allotted. Literature/publications can support both short and long-term health outcomes: increasing patient and provider satisfaction, improving the quality-of-life, decreasing risk of complications, and costs.

In each case, the team is needed to provide the ongoing care and education, glycemic management, health promotion, reduction of risks, telephone interventions, etc., which are guided by principles (13), clinical guidelines (3) and standards (2), as well as the 'process' of team education.

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