Traditional or centralized models of diabetes care: The multidisciplinary diabetes team approach

,

Article

Traditional or centralized models of diabetes care: The multidisciplinary diabetes team approach

November 2011 · Vol. 60, No. 11 Suppl: S6-S11

By

Christina R. Bratcher, MD, FACE

References

1. Codispoti C, Douglas MR, McCallister T, Zuniga A. The use of a multidisciplinary team care approach to improve glycemic control and quality of life by the prevention of complications among diabetic patients. J Okla State Med Assoc. 2004;97(5):201-204.

2. McGill M, Felton AM. New global recommendations: a multidisciplinary approach to improving outcomes in diabetes; Global Partnership for Effective Diabetes Management. Prim Care Diabetes. 2007 Feb;1(1):49-55.Epub 2006 Dec 19.

3. Aschner P, LaSalle J, McGill M. The team approach to diabetes management: partnering with patients; Global Partnership for Effective Diabetes Management. Int J Clin Pract Suppl. 2007;(157):22-30.

4. Antoline C, Kramer A, Roth M. Implementation and methodology of a multidisciplinary disease-state-management program for comprehensive diabetes care. The Permanente Journal. 2011;15(1):43-48.

5. AADE Guidelines for the Practice of Diabetes Self-Management Education and Training (DSME/T). American Association of Diabetes Educators. 2009. Revised 2010.

6. Franz MJ, Powers MA, Leontos C, et al. The evidence for medical nutrition therapy for type 1 and type 2 diabetes in adults. J Am Diet Assoc. 2010;110(12):1852-1889.

7. Sisson E, Kuhn C. Pharmacist roles in the management of patients with type 2 diabetes. J Am Pharm Assoc (2003). 2009;49(suppl 1):S41-S45.

8. Wubben DP, Vivian EM. Effects of pharmacist outpatient interventions on adults with diabetes mellitus: a systematic review. Pharmacotherapy. 2008;28(4):421-436.

9. US Department of Health and Human Services, Centers for Medicare and Medicaid Services. CMS Manual System: Pub 100-02 Medicare Benefit Policy. August 2009. http://www.cms.gov/transmittals/downloads/R109BP.pdf. Accessed April 26, 2011.

10. Hogg W, Lemelin J, Dahrouge S, et al. Randomized controlled trial of anticipatory and preventive multidisciplinary team care: for complex patients in a community-based primary care setting. Can Fam Physician. 2009;55(12):e76-e85.

11. Maislos M, Weisman D. Multidisciplinary approach to patients with poorly controlled type 2 diabetes mellitus: a prospective, randomized study. Acta Diabetol. 2004;41(2):44-48.

12. Yu GC, Beresford R. Implementation of a chronic illness model for diabetes care in a family medicine residency program. J Gen Intern Med. 2010;25(suppl 4):S615-S619.

13. Norris SL, Lau J, Smith SJ, Schmid CH, Engelgau MM. Self-management education for adults with type 2 diabetes: a meta-analysis of the effect on glycemic control. Diabetes Care. 2002;25(7):1159-1171.

14. Deakin TA, McShane CE, Cade JE, Williams R. Group based training for self-management strategies in people with type 2 diabetes mellitus. Cochrane Database Syst Rev. 2005;(2):CD003417.-

15. Diabetes America. Information for Health Professionals. http://www.diabetesamerica.com/healthprofessionals.cfm. Accessed April 26, 2011.

16. National Committee for Quality Assurance. Diabetes Recognition Program. 2011. http://www.ncqa.org/tabid/1023/Default.aspx. Accessed May 5, 2011.

17. Davis A. Everything’s bigger in Texas: Study shows Texas employers post significant diabetes savings using specialty provider. Employee Benefit News. 2010 Apr 1:30-31. http://digital.benefitnews.com/benefitnews/20100401?pg=3#pg30. Accessed April 28, 2011.

18. Gagliardino JJ, Etchegoyen G. A model educational program for people with type 2 diabetes: a cooperative Latin American implementation study (PEDNID-LA). Diabetes Care. 2001;24:1001-1007.

Table of Contents

Introduction

Traditional or centralized models of diabetes care: The multidisciplinary diabetes team approach

Nontraditional or noncentralized models of diabetes care: Medication therapy management services

Nontraditional or noncentralized models of diabetes care: Boutique medicine

Nontraditional or noncentralized models of diabetes care: Models in which other HCPs take on a leading role in managing patients’ diabetes

TAKE-HOME POINTS

Specialized diabetes care (SDC) centers utilize a multidisciplinary diabetes team to provide patients with highly individualized care
Patients at SDC centers receive their integrated diabetes care in one place—the “one-stop” approach
The components of the SDC center model are:
– Medical care
– Individualized diabetes education
– Nutrition
– Exercise and lifestyle coaching
– Counseling
– Monitoring of drug effects
This model results in improved patient outcomes and reduced overall costs

Introduction

Although patients with diabetes may be well managed by primary care physicians, the application of a team approach to the delivery of care enables a range of health care providers to integrate their skills to facilitate improved patient management and outcomes. Centralized diabetes care clinics bring together the expertise of primary care physicians, endocrinologists, registered nurses, nurse practitioners (NPs), physician assistants (PAs), certified diabetes educators (CDEs), dietitians, and/or pharmacists into a multidisciplinary diabetes team (MDT) that operates under a single roof to provide integrated care.

This approach contributes to comprehensive patient management and improved disease outcomes.^1-4 Specialized diabetes care (SDC) centers rely on an MDT structure to provide patients with individualized disease management. The centralized model encourages ongoing communication and interaction between the patient and multiple members of the care team. These SDC centers are typically statewide or regional.

A centralized model of diabetes care

Overview and organizational structure

SDC centers offer medical services for patients with diabetes, based on 4 cornerstones of disease management: medical care; personalized education; nutrition counseling; and lifestyle and exercise coaching. The centralized model involves patients in the management of their diabetes, with the goal of promoting wellness and preventing complications. Specifically, physicians, nurses, and dietitians work with patients to develop personalized treatment plans to prevent and detect diabetes-related complications. At Diabetes America centers, team members include physicians, NPs, PAs, and CDEs. Some SDC centers do not employ pharmacists, while other centralized diabetes clinics have a pharmacist on staff.

Within the MDT structure, the physician, NP, or PA is primarily in charge of monitoring patient health and making pharmacologic decisions; he or she is aware of the full range of available therapeutic options for diabetes management, as well as clinical practice guidelines and emerging evidence. Physicians, in conjunction with the MDT, also provide expert knowledge regarding new management technologies, such as insulin pumps and glucose sensors. Lastly, physicians provide expertise and patient management in other aspects of care, including hypertension and lipid management, and the treatment of diabetes-related complications. NPs and PAs work closely with physicians to coordinate personalized patient treatment plans; these professionals also provide integral support and education to patients who are newly diagnosed with diabetes and/or who are making the transition to insulin therapy (when patients face new lifestyle considerations, including daily glucose monitoring and insulin shots).

In addition to encouraging effective self-management and patient autonomy, SDC patients are provided with comprehensive, ongoing patient education delivered by CDEs. The role of the CDE is to promote positive health behaviors across all areas of diabetes self-management.⁵ The curriculum employed in our centers is consistent with the recommendations of the American Association of Diabetes Educators (AADE) and the American Diabetes Association (ADA). Patients learn about diabetes pathophysiology and management, circulatory health, medical nutrition therapy, and eye health in individual sessions, group classes, or seminars. The timing and sequence of training and education is predicated on patients’ needs and schedules. Additionally, CDEs are responsible for specific diabetes management tasks; for example, they can discuss treatment issues, medication titration, or dose adjustments, based on patient feedback. A patient’s need for education is evaluated during the clinical part of the visit. For example, when a physician initiates insulin treatment, the CDE would provide all necessary information and training to allow the patient to successfully self-administer insulin.

Dietitians help patients develop personalized nutrition plans, including meal and weight management plans, with the goal of developing targeted lifestyle change programs based on personal preferences. A recent review has confirmed that medical nutrition therapy delivered by registered dietitians is effective and essential in the management of diabetes.⁶ Diabetes America centers offer nutrition education in individual and classroom sessions, and encourage patients, as well as their families and caregivers, to attend. These sessions cover issues such as carbohydrate counting, reading and understanding nutrition labels, healthy portion sizes, meal planning, and weight management. Fitness and nutrition experts educate patients on the basics of healthy lifestyle, and offer tools to help patients reach their goals. In addition, patients are counseled on sick-day management, coping mechanisms for stress, and skin and foot care. The coaching approach is essential to ease patients’ adjustment into lifestyle changes essential for optimal diabetes management.