Redesigning the

Health Care Team

National Diabetes Education Program 

Diabetes Prevention

and Lifelong Management
The U.S. Department of Health and Human Services’ National Diabetes Education Program is 

jointly sponsored by the National Institutes of Heath and the Centers for Disease Control and Prevention 

with the support of more than 200 partner organizations.

www.YourDiabetesInfo.org 1-888-693-NDEP (1-888-693-6337) TTY: 1-866-569-1162

NIH Publication No. 11-7739 NDEP-37 Revised June 2011
1 

Credits and Acknowledgments.....................................................................................2

Executive Summary .......................................................................................................3

1. Introduction.................................................................................................................5

2. Chronic Disease and the Health Care Delivery System.......................................7

Health care environment............................................................................................7

Primary care providers...............................................................................................7

Models for chronic care delivery ..............................................................................7

3. What Makes a Successful Team? ............................................................................9

Six Team-Building Steps.........................................................................................10

Five Steps to Maintain a Successful Team ............................................................12

4. Non-traditional Team Care Approaches..............................................................14

Telehealth—Team care without walls....................................................................14

Shared medical appointments and group education ..............................................18

5. Payment & Cost-Effectiveness Data for Diabetes Education & Services.......20

6. Collaborative Care in Practice...............................................................................22

Practice setting .........................................................................................................22

 Community settings.........................................................................................22 

 Managed care...................................................................................................24 

 Multidisciplinary foot care clinics..................................................................24

 Primary care clinics.........................................................................................25

Health care professional involvement.....................................................................25

 Dental professional team members ................................................................25

 Depression care managers...............................................................................26

 Eye care professionals.....................................................................................26

 Nurse and dietitian and certified diabetes educators.....................................27

 Pharmacists......................................................................................................27

 Podiatrists ........................................................................................................29

 Registered dietitians.........................................................................................30

 Registered nurses.............................................................................................31 

7. Summary....................................................................................................................31

Case Studies: Implementing Team Care

1. Telehealth Enhances Diabetes Team Care in Hawaii .......................................15

2. Florida Initiative in Telehealth and Education for Children with Diabetes.....16 

3. A Story about Group Visits.................................................................................19 

4. Using Community Health Workers to Improve Quality in Diabetes Care......23 

5. A Collaborative Team Approach to Managing Diabetes in a Clinic Setting ..24 

6. Clinica Family Health Services: Enhanced Team Functioning........................26

7. Introducing Diabetes Education Services in Rural Communities....................28

8. A Podiatric Limb Preservation Team in Action................................................30

Appendices

1. Stratifying Care According to Patient Population Needs..................................32

2. Scope of Practice for Diabetes Educators & Board-Certified Advanced 

 Diabetes Management Practitioners...................................................................34

3. Quality Improvement Indicators for Diabetes Care ..........................................35

4. Medicare for People with Diabetes....................................................................36

Team Care-Related Resources...................................................................................37

References......................................................................................................................39

Table of Contents
2 

Credits and Acknowledgments

The U.S. Department of Health and Human Services’ National Diabetes Education Program (NDEP) is jointly 

sponsored by the National Institutes of Health and the Centers for Disease Control and Prevention, with the support of 

more than 200 partner organizations. The NDEP involves public and private partners in activities designed to improve 

treatment and outcomes for people with diabetes, promote early diagnosis, and ultimately prevent the onset of this 

serious and costly disease. These partnerships help to make NDEP goals a reality. The NDEP greatly appreciates the 

expertise of the following people and hereby acknowledges their contributions to the development of this guide.

CONTENT ADVISORY GROUP

W. Lee Ball, Jr., O.D., F.A.A.O. Amparo Gonzalez, R.N., C.D.E., F.A.A.D.E. 

American Optometric Association American Association of Diabetes Educators

Mary Jo Goolsby, Ed.D., M.S.N., N.P-C., F.A.A.N.P. M. Sue Kirkman, M.D.

American Academy of Nurse Practitioners American Diabetes Association

Amy Nicholas, Pharm.D. Patti Urbanski, M.Ed., R.D., L.D., C.D.E. 

American Pharmacists Association American Dietetic Association

NDEP Executive Committee 

Ann Albright, Ph.D., R.D.

Division of Diabetes Translation, Centers for Disease 

Control and Prevention

Lawrence Blonde, M.D.

Chief of Endocrinology and Metabolic Diseases and 

Vice Chairman of Medicine at the Ochsner Clinic in 

New Orleans

Jeff Caballero, M.P.H.

Association of Asian Pacific Community Health 

Organizations

Judith Fradkin, M.D.

Division of Diabetes, Endocrinology, and Metabolic 

Diseases, National Institute of Diabetes and Digestive 

and Kidney Diseases, National Institutes of Health

Martha M. Funnell, M.S., R.N., C.D.E.

Chair, National Diabetes Education Program

Michigan Diabetes Research and Training Center

NDEP Partner Representatives 

Kristina Ernst, R.N., C.D.E., Division of Diabetes 

Translation, Centers for Disease Control and Prevention

NDEP Health Care Professional Work Group 

Members 

Barbara Bartman, M.D., M.P.H.; John Buse, M.D., 

Ph.D.; Michael Gonzalez-Campoy, M.D., Ph.D., 

F.A.C.E.; Joe Humphey, M.D.; Bob McNellis, P.A., 

M.P.H.; Suzen M. Moeller, M.D., Ph.D.; Michael 

Parchman, M.D., M.P.H., F.A.A.F.P.; Sandy Parker, 

R.D., C.D.E.; Leonard Pogach, M.D., M.B.A.; Kathy 

Tuttle, M.D, F.A.S.N., F.A.C.P.

WRITER/EDITOR

Elizabeth Warren-Boulton, R.N., M.S.N.

Hager Sharp, Inc., Washington, DC

REVIEWERS

NDEP Directors

Joanne Gallivan, M.S., R.D.

Director, National Diabetes Education Program, 

National Institute of Diabetes and Digestive and 

Kidney Diseases, National Institutes of Health

Diane Tuncer, B.S.

Deputy Director, National Diabetes Education 

Program, National Institute of Diabetes and Digestive 

and Kidney Diseases, National Institutes of Health

Jude McDivitt, Ph.D.

Director, National Diabetes Education Program, 

Division of Diabetes Translation, Centers for Disease 

Control and Prevention

Betsy Rodriguez, R.N., M.S.N., C.D.E.

Deputy Director, National Diabetes Education 

Program, Division of Diabetes Translation, Centers for 

Disease Control and Prevention

NDEP Pharmacy, Podiatry, Optometry, and Dental 

Professionals Work Group Members

Meg D. Atwood, R.D.H., M.P.S.; Dennis R. Frisch, 

D.P.M.; Martin Gillis, D.D.S., M.A.Ed.; Philip T. 

Rodgers, Pharm.D., B.C.P.S., C.D.E., C.P.P., F.C.C.P.; 

Don Zettervall, R.Ph., C.D.E., C.D.M. 

NDEP Diabetes in Children and Adolescents Work 

Group Members

Nichole Bobo, R.N., M.S.N., A.N.P.; Ryan Brown, M.D., 

F.A.A.P.; Jane K. Kadohiro, Dr.P.H., A.P.R.N., C.D.E.; 

Mary Pat King, M.S.; Barbara Linder, M.D.; Katie 

Marschilok, R.N., C.D.E., BC-ADM; Laura Shea, R.N., 

C.D.E.; Janet Silverstein, M.D.
3 Redesigning the Health Care Team

Executive Summary

This guide is designed to help health care professionals 

and health care organizations implement collaborative, 

multidisciplinary team care for adults and children with 

diabetes in a variety of settings. Collaborative teams 

that provide continuous, supportive, and effective care 

for people with diabetes throughout the course of their 

disease are a model for the prevention and management 

of chronic diseases. Well-implemented diabetes team 

care can be cost-effective and the preferred method of 

care delivery, particularly when services include health 

promotion and disease prevention, in addition to intensive clinical management. Team care is a key component 

of health care reform initiatives that incorporate an integrated health care delivery system, especially those for 

chronic disease prevention and management.

Diabetes is a serious, common, and costly disease that 

affects 25.8 million Americans, or 8.3 percent of the 

U.S. population. About 90 to 95 percent of people with 

diabetes have type 2, which usually occurs in adults 

over age 45 but is increasingly occurring in younger age 

groups. Type 1 is usually diagnosed during childhood, 

although adults can also develop the disease. Some 

patients may have features of both type 1 and type 2 

diabetes, which further complicates disease treatment and 

management. In addition, at least 79 million U.S. adults 

have pre-diabetes, which places them at increased risk for 

cardiovascular disease and type 2 diabetes. The chronic 

complications of diabetes (cardiovascular disease, vision 

loss, kidney failure, nerve damage, and lower-extremity 

amputations) result in higher rates of disability, increased 

use of health care services, lost days from work, unemployment, decreased quality of life, and premature 

mortality. Acute complications can also result in lost 

days from school. The total cost of diabetes in the United 

States in 2007 was $174 billion. 

Despite its multi-system effects, it is possible to 

prevent or delay the onset of type 2 diabetes as well 

as to effectively manage both type 1 and type 2. 

Unequivocal evidence shows that early detection and 

early and aggressive ongoing therapeutic intervention 

significantly reduces the enormous human and economic 

toll from diabetes. To achieve the health benefits that 

modern science has made possible, the principal clinical 

features of diabetes—hyperglycemia, dyslipidemia, and 

hypertension—need to be prevented and managed within 

a system that provides continuous, proactive, planned, 

patient-centered, and population-based care. Primary care 

physicians, physician assistants, and nurse practitioners 

all play important roles in the delivery of primary care 

for people with chronic diseases in the United States. To 

reduce the risk of microvascular complications, this care 

needs to include regular assessment of the eyes, kidneys, 

teeth and mouth, and lower extremities in people with 

diabetes. System constraints, however, can make it difficult for primary care providers to carry out all of these 

essential elements of comprehensive diabetes care. 

The challenge is to broaden delivery of care by expanding the health care team to include several types of health 

care professionals. Team care can minimize patients’ 

health risks by assessment, intervention, and surveillance 

to identify problems early and initiate timely treatment. 

Increased use of effective behavioral interventions to 

lower the risk of diabetes and treatments to improve 

glycemic control and cardiovascular risk profiles can 

prevent or delay progression to kidney failure, vision 

loss, nerve damage, lower-extremity amputation, and 

cardiovascular disease. Patients’ participation in treatment decisions, personal selection of behavioral goals, 

patient education and training, and active self-management can improve diabetes control. This in turn leads to 

increased patient satisfaction with care, better quality of 

life, improved health outcomes, and ultimately, lower 

health care costs.

Collaborative teams vary according to patients’ needs, 

patient load, organizational constraints, resources, clinical 

setting, geographic location, and professional skills. It 

is essential that a key person coordinate the team effort. 

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. 
Redesigning the Health Care Team 4 

For Team Care-Related resources see page 37. 

The benefits of diabetes team care include efficient 

patient education, improved glycemic control, increased 

patient follow-up, higher patient satisfaction, lower risk 

for the complications of diabetes, improved quality of 

life, reduced hospitalizations, and decreased health care 

costs. It is difficult, however, to measure team care 

effects beyond these intermediate outcomes. Future 

evaluations of model medical home health care delivery 

programs will likely provide additional data about 

improved patient outcomes. 

Effective team care requires

•	 the commitment and support of organization leadership

•	 the active participation of the patient and health care 

professional team members

•	 ways to identify the patient population via an information tracking system 

•	 adequate resources

•	 payment mechanisms for team care services

•	 a coordinated communication system

•	 documentation and evaluation of outcomes and adjustment of services as necessary

Teams can work effectively in many varied settings to 

improve the quality and effectiveness of diabetes care. 

Payment of services provided by health care professionals other than primary care providers and specialists—

such as registered nurses, registered dietitians, and 

psychologists—although improving, often is inadequate. 

Examples in this guide from the peer-reviewed literature 

and case studies show the diversity and effectiveness of 

health care professional teams working with people with 

diabetes. These include 

•	 community-based primary care providers who involve 

a pharmacist and dietitian in implementing treatment 

algorithms, nurse and dietitian case managers, and 

educators who help to improve patients’ weight loss 

and A1C values

•	 a nurse practitioner-physician team that manages 

patients with diabetes and hypertension

•	 nurse and dietitian diabetes educators who help 

people with and at risk for diabetes achieve behaviorchange goals leading to better clinical outcomes and 

who work with primary care physicians and staff to 

provide “diabetes day” individual and group patient 

appointments

•	 school nurses who contribute to diabetes prevention 

and management in their students

•	 a nurse, social worker, or psychologist who works 

closely with older patients, their primary care physician, and a consulting psychiatrist to treat depression

•	 health care professionals who use telehealth to 

improve eye care, nutrition counseling, and diabetes 

self-management education

•	 pharmacists who work with company employees who 

have diabetes and their physicians to improve clinical 

measures and lower health care costs

•	 trained community-based fitness instructors who 

deliver group-based lifestyle interventions in YMCA 

settings to people at risk for diabetes to achieve 

increases in physical activity and significant weight 

loss 

•	 trained community health workers who bridge the 

gap between traditional health care teams to improve 

access to diabetes health care, complications assessment, and education in underserved communities

•	 podiatrists and other health care professionals who 

help reduce lower-extremity amputation rates in foot 

care clinics

•	 dental and eye care professionals who help prevent and 

manage diabetes complications 

There is evidence that a team approach reduces risk 

factors for type 2 diabetes, can improve diabetes 

management, and can lower the risk for chronic diabetes 

complications. This evidence, in turn, shows that an 

opportunity exists for health care professionals and health 

organizations to improve the health of people with diabetes. It is important, however, that studies of team care 

interventions involving the skills of numerous health care 

professionals should continue to elucidate effective ways 

to implement team care to improve patients’ well-being 

and assess the costs involved. 
5 Redesigning the Health Care Team

The problem

Diabetes is a serious, common, and costly chronic 

disease that affects 25.8 million Americans, or 8.3 

percent of the U.S. population. About 1.9 million new 

cases are diagnosed annually.[1] Diabetes disproportionately affects African Americans, Hispanic Americans, 

American Indians, Asian and Pacific Islanders, and older 

Americans. Complications from the disease include 

cardiovascular disease, vision loss, kidney failure, nerve 

damage, and lower-extremity amputations. These complications can subsequently result in higher rates of disability, increases in the use of health care services, lost days 

from work, unemployment, illness, and premature death. 

Type 1 and type 2 diabetes

Type 1 diabetes usually strikes children and young 

adults, although disease onset can occur at any age. In 

adults, type 1 diabetes accounts for 5 to 10 percent of all 

diagnosed cases of diabetes.[1] About 90 to 95 percent 

of people with diabetes have type 2 diabetes, which 

more commonly occurs in adults older than age 45 

who are obese and have a family history of the disease. 

Overweight and obese children are at increased risk for 

developing type 2 diabetes during adolescence and later 

in life, with approximately one in three cases of new 

onset diabetes being type 2 in youths younger than age 

18. This increased incidence of type 2 diabetes in youths 

is a first consequence of the obesity epidemic among 

young people and a significant and growing public health 

problem.[2] 

Intensive versus standard therapy

Investigators in the Diabetes Control and Complications 

Trial (DCCT), a large clinical trial of intensive versus 

standard therapy for adults with type 1 diabetes, reported 

in 1993 that intensive glucose control reduced eye, 

nerve, and kidney damage. Findings reported in 2005 

from the Epidemiology of Diabetes Interventions and 

Complications[3] (DCCT follow-up) study and in 2008 

from the 10-year follow-up of the United Kingdom 

Prospective Diabetes Study (UKPDS)[4], show that 

intensive glucose control (A1C* goal <7 percent) in 

newly diagnosed people with either type of diabetes not 

only has benefits during the period of intensive therapy 

but also has a “legacy effect” in which micro- and macrovascular benefits are realized years later. 

Cost of diabetes

The total cost of diabetes in the United States in 2007 

was $174 billion, including $116 billion for direct 

medical costs and $58 billion in indirect costs, such as 

disability, time lost from work, and premature death.[5] 

Of the direct costs, 50 percent were for hospital inpatient 

care, 12 percent for diabetes medications and supplies, 

11 percent for prescriptions to treat complications of 

diabetes, and 9 percent for physician office visits. 

Computer modeling has shown that compared to standard 

treatment, early, effective diabetes management can 

reduce treatment costs for diabetes complications of the 

eye, kidney, and extremities.[6] There is a marked correlation between glycemic control and the cost of medical 

care, with medical charges increasing significantly for 

every 1 percent increase in A1C above 7 percent.[7] The 

increase in medical charges accelerates as the A1C value 

increases. 

Prevention or delay of diabetes onset

About 79 million American adults have pre-diabetes and 

are likely to develop type 2 diabetes within 10 years, 

unless they take steps to prevent or delay diabetes. 

1. Introduction 
Redesigning the Health Care Team 6 

Pre-diabetes occurs when a person’s blood glucose is 

higher than normal but not high enough for a diagnosis 

of diabetes. The Diabetes Prevention Program (DPP), a 

large prevention study of people at high risk for diabetes, 

showed in 2002 that lifestyle intervention reduced the 

incidence of diabetes by an average of 58 percent over 

3 years (by 71 percent among adults age 60 or older); 

diabetes incidence was reduced by 31 percent in those 

taking metformin.[8] A cost-effectiveness model estimated in 2005 that the DPP lifestyle intervention would 

cost society about $8,800 per quality-adjusted life-year 

saved (within a typically acceptable range). Metformin 

would cost about $29,900 per quality-adjusted life-year 

saved and was considered not cost-effective after age 

65.[9]

In 2009, a 10-year follow-up of DPP participants, the 

Diabetes Prevention Program Outcomes Study, found 

that diabetes incidence was reduced by 34 percent in 

the lifestyle group and 18 percent in the metformin 

group compared with placebo. These results show that 

prevention or delay of diabetes with lifestyle intervention or metformin can persist for at least 10 years.[10] 

Interventions to prevent or delay type 2 diabetes in 

people with pre-diabetes are feasible and could be costeffective. 

Models for better diabetes care

The Chronic Care model,[11, 12] the Medical Home 

model,[13] and the Healthy Learner model[14] provide 

frameworks for effective care of diabetes and other 

chronic diseases. All incorporate team care as a vital 

component of delivery system design. These models will 

likely guide health care reform initiatives that incorporate 

an integrated health care delivery system.

This publication, Redesigning the Health Care Team: 

Diabetes Prevention and Lifetime Management, provides 

the following

•	 an overview of the evidence that supports team care as 

a component of effective diabetes management

•	 practical information to help health care professionals 

and organizations incorporate team care into practice 

in a variety of settings

•	 steps for forming and maintaining a successful team 

•	 eight case studies that demonstrate real-world team 

care in several different settings

For Team Care-Related resources see page 37. 

* NDEP and its partners have adopted the simple name “A1C” for the hemoglobin A1C test. 

A1C is a standardized blood test that indicates the average blood glucose over the previous 8 

to 12 weeks. A1C values and self-monitoring of blood glucose can be used to guide therapy 

to achieve glycemic targets. People with diabetes need to know their own A1C values and 

whether they are reaching their targets. 
7 Redesigning the Health Care Team

Health care environment 

Today’s health care environment is affected by several 

significant factors, including greater numbers of aging 

and older people, the development of new technologies, 

advances in medical treatments, and the tremendous 

increase in scientific knowledge about health and illness. 

One result is that more people are living longer with 

diabetes and its complications. In spite of the growing 

diabetes population and the high cost of this disease, 

people with diabetes are often poorly served by the 

current health care system that is primarily symptom 

oriented and focused on acute illness. Additionally, 

payment is heavily weighted toward medical procedures 

or treatment of late complications of disease, rather than 

toward the cognitive and time-consuming efforts required 

for successful primary or secondary disease prevention. 

Current payment policies need modification to support 

team care for effective chronic disease management. 

Primary care providers

Primary care physicians, physician assistants (PAs), and 

nurse practitioners (NPs) all play important roles in the 

delivery of primary care for people with chronic diseases 

in the United States. Although endocrinologists or other 

diabetes specialty physicians are involved in caring for 

many people with diabetes, primary care physicians 

provide more than 80 percent of diabetes care.[15] In the 

past, physician shortages in rural or other underserved 

communities were addressed in part by PAs and NPs. 

Currently, however, about 33 percent of PAs practice in 

primary care, 15 percent practice in rural areas, and 

8 percent in federally qualified health centers and 

community health facilities.[16] The PA profession 

appears to be moving away from primary care toward 

specialty training to support specialty physician practices.

[17] NPs have traditionally worked in primary care, and 

a recent national survey reported that the average NP 

was female (95 percent), 48 years old, in practice for 

10.5 years, and a family NP (49 percent) involved in 

direct patient care.[18] Schools of nursing are increasing 

training programs for doctoral-level comprehensive care 

practitioners.[17] 

Systems constraints can make it difficult for primary care 

providers to carry out elements of comprehensive diabetes care, such as to 

•	 identify a practice’s sub-population of patients 

with diabetes and target those at highest risk for 

co-morbidities

•	 conduct ongoing self-management education and 

behavioral interventions

•	 provide remote management of glycemia

•	 promote risk-factor reduction and healthy lifestyles

•	 provide periodic examinations for early signs of 

complications[19] 

The challenge is to broaden the delivery of primary care 

by expanding the health care team to effectively address 

the various elements of comprehensive diabetes care. 

Models for care delivery 

The models briefly described on the next page share 

many similar elements. Each element, however, is a 

2. Chronic Disease and the Health Care 

Delivery System
Redesigning the Health Care Team

complex undertaking, and the level of guidance available 

varies in its implementation and evaluation of effectiveness for improving chronic care. 

Chronic care model

The chronic care model[11] presents six interrelated 

elements for effective care of chronic diseases: 

•	 the health system–culture, organizations, and mechanisms to promote safe, high-quality care

•	 delivery system design–for clinical care and selfmanagement support, including team care

•	 decision support–based on evidence and patients’ 

preferences

•	 clinical information systems–to organize patient and 

population data

•	 self-management support–to enable patients to manage 

their health and health care

•	 community involvement–to mobilize patient resources 

In 2002, a systematic review included diabetes care 

programs that featured at least one of four chronic 

care model elements: delivery system design, decision 

support, clinical information systems, and self-management support.[20] This review found that 32 of 39 

programs improved at least one process measure (e.g., 

testing A1C) or one outcome measure (e.g., lowering 

A1C) for patients with diabetes by implementing at least 

one of the four chronic care model elements. Since the 

methodological quality of the studies was not uniformly 

high and the interventions differed among studies, 

the review authors cautioned about generalizing these 

findings. 

In 2005, a meta-analysis[21] was conducted of randomized and non-randomized controlled trials in chronic 

disease that addressed one or more elements of the 

chronic care model. Diabetes was one of the four chronic 

diseases studied. This analysis found that interventions 

that incorporated at least one element of the model had 

consistently beneficial effects on process and outcome 

measures across the four diseases. Interventions for 

diabetes led to a 0.3-0.47 percent reduction in A1C but 

no measurable benefit in quality of life. The elements 

responsible for these benefits could not be determined 

from the data. 

Medical home model

The American Academy of Pediatrics originally used the 

term “medical home” to describe a partnership approach 

to providing family-centered, comprehensive health 

care.[22] The model has since been embraced by the 

major U.S. primary care organizations, other health care 

provider groups, private health care purchasers, labor 

unions, and consumer organizations. This evolving model 

of care is playing an important part in health care reform.

[23] 

Also known by other names such as the Advanced 

Primary Care model, the medical home links multiple 

points of health delivery by utilizing a team approach 

with the patient at the center. The model emphasizes 

prevention, health information technology, coordination 

of care, and shared decision making among patients and 

their health care team.[24]

Nurses, diabetes educators, dietitians, pharmacists, podiatrists, eye care providers, dental professionals, and other 

health care professionals are likely to play important roles 

in the medical home model by working with primary 

care providers to collaboratively provide comprehensive 

diabetes care. Such care includes management of blood 

glucose, lipids, and blood pressure; weight management; 

smoking cessation counseling; and diabetes complication care and prevention. Implementation of the medical 

home model will require modification of current health 

care provider payment policies to support team care.[25] 

Medical home demonstration projects for Medicare 

beneficiaries are planned for community health centers 

across the country and for primary care practices in 

eight states. Medicare may join Medicaid and private 

insurers to conduct state-based primary care initiatives. 

These projects will incorporate payment modification 

for team care and evaluate the effectiveness of the model 

in improving health care quality and reducing costs.[24] 

Their findings will help guide future efforts to integrate 

and disseminate the model’s key components, including 

payment mechanisms into other settings.[13] 

Healthy learner model

The Healthy Learner Model extends the Chronic Care 

Model to include professional school nurses in chronic 

disease management for students in kindergarten through 

grade 12.[14] This model enables improved communication and coordination among health care professionals, 

students with chronic diseases and their families, and 

school personnel. The goal is to maintain student health 

in the school setting. Leadership involving communities and school districts is critical to the model as is 

evaluation of success in maintaining student health. The 

Healthy Learner Model has been successfully implemented and evaluated in Minneapolis Public Schools and 

St. Paul Public Schools to improve the health of children 

with asthma.[26] The model needs further application to 

diabetes and replication in other school districts. 

8 
Redesigning the Health Care Team

and primary care physicians, or adding a new team 

member with an expanded professional role. 

•	 Effective case management involved nurse or pharmacist case managers who followed physician-supervised 

algorithms to make medication adjustments. 

Similar results were found in a group of low-income 

Latino patients who received supervised, nurse-directed 

care using detailed treatment algorithms.[33] 

Multidisciplinary teams are involved in pediatric care to 

effectively manage youths with diabetes.[34, 35] Team 

care contributed to the Steno-2 Study[36], a target-driven, 

long-term, intensified intervention that significantly 

9 

Integral role of the patient and family

Team care integrates the skills of primary care providers and other health care professionals with those of 

the patient and family members into a comprehensive 

lifetime diabetes management program[19, 27] that is 

of high quality and is cost-neutral[28] or cost-effective.

[29] The patient is the central team member, since most 

diabetes care is carried out by the person with diabetes or 

his or her family. Patients need to understand their roles 

as self-care managers and decision-makers to effectively 

work with members of their health care team. Family 

members assume most of this role for children and teens 

with diabetes. 

Health care professionals

Teams usually include health care professionals with 

complementary skills who are committed to a common 

goal and approach.[30] Some health care professionals may choose to become certified diabetes educators 

(CDEs). (See Appendix 2 for information on the role of 

CDEs.) 

Team composition varies according to patients’ needs, 

patient load, organizational constraints, resources, clinical setting, geographic location, and professional skills.

[31] It is essential that a key person coordinate the team 

effort. Non-traditional approaches to health care such 

as telehealth, shared medical appointments, and group 

education all expand access to team care.

What can team care accomplish? 

Many examples of team management for people with 

diabetes can be found in the scientific literature. A 2006 

meta-analysis assessed the impact on glycemic control of 

11 distinct strategies for quality improvement in adults 

with type 2 diabetes.[32] Across 66 trials (50 randomized, three quazi-randomized, and 13 controlled beforeafter trials), two of 11 categories of quality improvement 

strategies were associated with reductions in A1C values 

of at least 0.5 percent. The two categories were team 

changes and case management. 

•	 Effective team changes included the use of multidisciplinary teams, shared care between specialists 

3. What Makes a Successful Team?

A flexible plan helps meet specific needs

Not every team member needs to be involved in every 

patient’s care. A flexible plan helps determine the most 

effective team, as needs will change over time. For 

example

•	 A podiatrist may be involved in care for people with 

neuropathy, ulcerations, and other foot pathology. 

Podiatrists can provide comprehensive annual diabetes foot care examinations.

•	 A pharmacist may assist patients with multiple 

co-morbidities, or those requiring polypharmacy.

•	 Nurse educators, diabetes educators, and case 

managers can provide initial and ongoing diabetes 

self-management education, diabetes management 

support, and medication management services.

•	 Eye care professionals (optometrists and ophthalmologists) can provide comprehensive eye and vision 

care, including an annual dilated eye exam.

•	 A psychologist or social worker may be part of a 

team providing child and adolescent care.

•	 Dental professionals conduct oral examinations and 

provide oral health education in some community 

health centers.

•	 Clinical care teams can be augmented by the support 

and resources of school nurses, home health nurses, 

community health workers, and other community 

partners. 
Redesigning the Health Care Team 10 

reduced the risk of cardiovascular disease and microvascular events in adults with type 2 diabetes and microalbuminuria.[37] Although team care may have played a role 

in the success of other large clinical trials, there is little 

discussion of its contribution in the literature.

How to build and maintain effective teams

Six Team-building Steps presents important considerations for those creating or expanding team care, 

regardless of setting or program size: commitment of 

leadership; contributing team members; an identifiable 

patient population; adequate resources; a system for coordinated, continuous high-quality care; and an effectiveness evaluation plan. 

Five Steps to Maintain a Successful Team presents 

elements that ongoing successful teams can promote: 

team coordination and communication; patient satisfaction, quality of life, and self-management; a community 

support network; patient follow-up; and the use of secure 

computerized clinical information systems.

Possible Diabetes Team Care Outcomes

Studies of diabetes team care in a variety of settings 

(see section 6) have shown improvements in one or 

more of the following 

•	 glycemic, lipid, and blood pressure control

•	 patient follow-up

•	 patient satisfaction

•	 risk for diabetes complications

•	 quality of life

•	 health care costs

Six Team-building Steps

These six steps identify important considerations for 

those creating or expanding team care, regardless of 

setting or program size. 

1. Ensure the commitment of leadership

The first step requires care providers and other key 

decision-makers to commit to the implementation of 

multidisciplinary team care and the necessary resources 

and infrastructure to enable the team to function. A planning group can then carry out the next steps.

R Select well-respected clinicians to serve as catalysts 

to generate interest and support among colleagues.

R Meet with primary care providers and other potential 

team members, policy makers, and payment 

specialists such as business or office managers to 

obtain their support.

R Involve core team members early in organizational 

and clinical decision-making to gain their active 

participation.

R Demonstrate team care on a small scale, if necessary, 

to assess its feasibility, effectiveness, and impact.

2. Identify team members

R Invite potential team members to commit to 

participation.

R Clarify the roles of team members to resolve issues 

related to leadership and role overlap or redundancy 

in the care delivery process.[38]

R Ensure mutual respect and a common vision.

3. Identify the patient population

R Initial assessment may be limited to general 

demographic characteristics and an estimate of 

the proportion of patients with type 1, type 2, and 

gestational diabetes.

R Further assessment could determine the presence 

of risk factors, number of patients with and without 

diabetes complications, severity of complications, the 

extent of comorbidities, use of health services, and 

delivery of preventive care.[39]
11 Redesigning the Health Care Team

R Once the diabetes patient population is known, 

the team might want to stratify the population into 

groups according to the intensity of services required. 

•	 Newly diagnosed patients with limited diabetes 

complications might benefit from relatively 

low-cost preventive care focused on risk factor 

reduction and health promotion. 

•	 Patients with diabetes complications or other 

comorbidities over the previous two-year period 

might need more intensive management with 

more extensive resources (see Appendix 1, 

Stratifying Team Care According to Patient 

Population Needs).

4. Assess resources

R Identify strengths and weaknesses in available 

resources (such as support staff, education materials, 

equipment, supplies, home care services, support 

groups, follow-up services, community resources). 

Ensure that adequate space, equipment, and supplies 

are available.

R Determine payment mechanisms for health care 

professional services, equipment, and supplies. 

R Assemble user-friendly, current diabetes prevention 

and management protocols, tools, and education 

materials to ensure the delivery of current, culturally 

sensitive, and consistent care. These include 

standards of care, treatment guidelines, protocols and 

algorithms, patient education materials, flowcharts, 

standing orders, chart stickers, and other recording 

and reminder systems (see various resources in 

Resources section).

5. Develop a system for coordinated, 

continuous, high-quality care

R Define the team philosophy, goals, and objectives.

R Develop a secure information system for patient 

identification, data collection, ongoing assessment, 

and monitoring the achievement of specific clinical 

performance measures such as hemoglobin A1C, 

blood pressure, and lipid target values, as well as 

patient satisfaction and quality-of-life indicators.

R Determine the structure and scope of the program or 

service. Teams can provide medical and clinical care; 

diabetes risk-reduction counseling; diabetes, lipid, 

and hypertension management; self-management 

education and medical nutrition therapy; 

psychosocial counseling; complications risk-factor 

reduction counseling; screening for complications; 

follow-up care; coordination of referrals to 

specialists; and access to supportive clinical and 

community resources. 

R Base care on evidence-based guidelines adapted from 

widely accepted standards or practice guidelines to 

meet local conditions.[40] (See various resources in 

Resources section.) 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.

R Structure a payment system for professional services 

(see Resources–AADE, ADietA, CMS). 

6. Evaluate outcomes and adjust as 

necessary 

Periodic process and outcome evaluations can help to 

improve team function and patient care. 

R Databases with analytic reports, pooled medical 

record audit findings, utilization data (such as 

hospital length-of-stay, emergency room visits, and 

total dollars spent) can help evaluate outcomes of 

team care, determine future progress, and indicate 

team success in meeting quality measures (see 

Appendix 3, Quality Improvement Indicators for 

Diabetes Care).

R Patient satisfaction and quality-of-life interviews 

or questionnaires for patients can provide valuable 

feedback to the team and may influence the scope 

and manner of care provided.

R Document clinical, behavioral, and financial 

outcomes to show payers and other stakeholders the 

value of the services and return on investment.

R If desired, teams could seek funding and resources 

from a nearby university or other facility for an 

evaluation expert for advice or to conduct a more 

formal program evaluation. 
Redesigning the Health Care Team 12 

Five Steps to Maintain a 

Successful Team

Regardless of the team structure and purpose, several 

important elements need attention for ongoing, successful team care. These elements are presented below in no 

particular order. 

1. Promote patient satisfaction, quality of 

life, and self-management

R Address patients’ concerns such as insurance 

coverage and billing, confidentiality, time spent 

waiting, accessibility of providers, and continuity of 

care, to improve patient satisfaction. 

R Provide self-management education to equip 

patients with the knowledge and skills to actively 

participate in their care, make informed decisions, 

set collaborative goals, carry out daily management, 

evaluate treatment outcomes, and communicate 

effectively with the health care team.

R Reassess and redefine collaborative goals and 

supportive care to sustain achievement of goals over 

time.

2. Promote a community support 

network 

The support of family, friends, and the entire community 

can help people with diabetes sustain self-management 

practices and a positive outlook over time. 

R Assess community support and resources such as 

institutional funding and grants from community 

agencies, groups, or services. Grants or industry 

support for indigent programs may be available.

R Determine available Medicare and other insurer 

payment for health care professional provider 

services (including diabetes patient education and 

nutrition counseling), equipment, and supplies (see 

CMS Resources).

R Help people with diabetes develop a community 

support network that includes family, friends, support 

groups, the faith community, and needed services 

such as transportation.

R Encourage community organizations to support 

routine physical activity and the concept of healthy 

foods for all to create an environment that can 

contribute to improved health outcomes and quality 

of life.

3. Maintain team coordination and 

communication

R Develop clear procedures to facilitate timely 

coordination of all required services.

R Consider using standard treatment algorithms (see 

various items in Resources).

R Reassess periodically to ensure continuity of care and 

patient satisfaction.

R Develop communication methods between team 

members and the patient such as team meetings, 

patient rounds, and journal clubs to promote 

cohesion and a common approach to patient care.

R Set individual patient clinical targets for blood 

glucose and lipid values, A1C, blood pressure, 

and body weight, and behavioral targets for food 

intake and physical activity. These targets provide 

a common ground for discussion of management 

strategies, collaborative goals, and evaluation of 

treatment outcomes.

R Develop and maintain consistent messages from all 

team members to enhance patient understanding and 

increase effective self-management behaviors. 

R Communicate and document pertinent information 

from team members, ideally via a computerized 

information system.

R Encourage mutual respect between team members 

and the patient.

A multidisciplinary planning and documentation tool 

for the medical record could include treatment goals, 

personal patient goals, and disease management including 

medications, medical nutrition therapy, self-management 

education, and referrals. Such a tool can help all team 

members to clarify responsibilities, coordinate care, and 

communicate the patient’s progress in a timely way.[38] 
13 Redesigning the Health Care Team

Referral reports from eye care, foot care, dental professionals, and others can be incorporated into the patient’s 

health record through computer-generated reports, medical record notes, and personal and telephone contact. (See 

NDEP Resources for a microvascular checklist.)

4. Provide follow-up

Ongoing patient follow-up and regular scheduled visits 

for diabetes education, support, management, and preventive care are important to team success. A system to 

monitor and recall individuals for treatment and appointments, planned visits, and ongoing collaborative goal 

setting will facilitate the provision of these services.

R Essential preventive services include foot 

examinations; screening for microalbuminuria, visual 

acuity, and glaucoma; retinal eye examinations; and 

oral screening and preventive dental care. 

R Provide follow-up care can be in the form of 

return face-to-face visits or interaction with 

other team members and community partners 

as well as telephone interviews and fax or email 

correspondence. Sending patients reminders and 

questionnaires encourages appointment keeping.

R Arranging for patients to send self-monitored data 

and to receive phone counseling and ongoing 

therapeutic management can reduce the need for 

multiple clinic or office visits, prevent adverse 

events, and increase access to care for patients in 

medically underserved locations.[41-43] 

5. Use health information technology 

Secure computerized clinical information systems can 

R identify patients with diabetes, centralize their 

data and laboratory values, suggest a change in 

medication dosage, and enable timely referrals to 

other providers or specialists 

R automatically remind the team to conduct selfmanagement education, provide preventive services, 

and schedule follow-up visits 

R help monitor quality of care by pooling medical 

record audit findings and comparing them with 

baseline measures or values attained in other practice 

settings

R collect and report outcomes
Redesigning the Health Care Team

4. Non-traditional Team Care Approaches 

Telehealth—Team care without walls

Telehealth applications

Telehealth (or telemedicine) is the use of secure highspeed Internet connections for real-time video conferencing for medical, diagnostic, monitoring, and therapeutic 

purposes when distance and/or time separates the participants. Telehealth can expand access to health care and 

education for patients and health care professionals in 

remote rural and medically underserved locations, as well 

as increase the delivery of evidenced-based medicine and 

improve the consistency of care. 

Telehealth applications that expand the reach of the 

diabetes team include

•	 primary care digital retinal imaging for diabetes eye 

screening to augment or enhance regular comprehensive vision and eye health exams

•	 video conferencing for provider education (such as 

“Brown Bag” conferences) 

•	 video conferencing for group diabetes education and 

individual counseling 

•	 individualized telehealth for medical nutrition counseling (covered by Medicare)

•	 remote monitoring of self tests for blood glucose and 

blood pressure 

•	 pediatric care for youth with type 1 diabetes in remote 

areas[44]

•	 shared web-based clinical information connecting the 

patient, endocrinologist, primary care provider, pediatric care experts, other specialists, and other team 

members

•	 secure email and remote management 

•	 web-based patient surveys and information libraries 

•	 customized patient portals or personal health records

•	 hospital “grand rounds” education sessions 

(See Case Studies 1 and 2 that address telehealth.)

Ocular telehealth programs 

These programs can deliver eye care in the form of 

retinal screenings to those with limited care access and 

may in some cases improve care for those with regularly 

available vision and eye health care. Validated telemedicine programs using remote digital imaging systems are 

able to detect diabetic retinopathy but may not adequately 

detect other ocular co-morbidities associated with diabetes, including refractive errors, glaucoma, cataracts, dry 

eye, nerve palsies, and iris neovascularization. Retinal 

images are examined remotely by trained professionals. 

The Indian Health Service (IHS)-Joslin Vision Network 

Teleophthalmology Program uses telemedicine technology to provide annual eye exams to American Indians 

and Alaska Natives with diabetes who live far from 

health care centers. A digital camera transmits photographs of a patient’s eye to a central reading center, 

where IHS eye doctors interpret the images and send 

a report to the patient and primary care physician. The 

report includes the level of diabetic retinopathy, the presence of any non-diabetic retinal disease, and a recommended course of treatment. A four-year study showed 

that the program resulted in

•	 50 percent increase in annual eye exams

•	 51 percent increase in laser treatments to prevent 

blindness

•	 lower cost with quality equal to or better than a traditional dilated eye exam

(See IHS resources.)

Designing, building, and implementing an ocular telehealth program for diabetic retinopathy requires a clearly 

defined mission, goals (e.g., to preserve vision, reduce 

vision loss, and provide better access to limited forms 

of eye care), and guiding principles. When possible, 

these goals should be consistent with using telehealth to 

augment or enhance existing comprehensive eye care 

services. (See Resources under American Optometric 

Association and the Ocular Telehealth for two key documents that help an organization develop an effective and 

sustainable program.) 

Early detection through annual screening and treatment 

of diabetic retinopathy can reduce vision loss by 90 

percent.[45] Remote assessment of diabetic retinopathy 

using telemedicine is an accurate and potentially low-cost 

way to identify retinal lesions and facilitate appropriate 

and timely use of specialty care. Future studies will hopefully provide cost-effectiveness data of this service. 

14 
15 Redesigning the Health Care Team

Case Study 1: Telehealth Enhances 

Diabetes Team Care in Hawaii 

Joe Humphry, M.D.

Setting

Ms. LK is a 54-year-old Hawaiian female living on 

the Hamakua Coast on the Island of Hawaii with her 

husband and daughter. She has had type 2 diabetes for 

10 years and associated hypertension and hyperlipidemia. 

She is under the care of a primary care physician at the 

rural community health center, which is about 10 miles 

from her home. 

Team members 

Team members include the patient and her family, 

primary care physician, eye specialist, chronic care nurse, 

community health worker, librarian, endocrinologist, and 

pharmacist.

Services provided at the Community Health 

Center

Ms. LK received her annual retinal screening using 

the teleophthalmology non-mydriatic camera at the 

health center. She previously had limited access to 

eye care. The retinal images were read by the Hawaii 

Telephthalmology Imaging Center, and the report was 

electronically sent to her primary care physician.

Ms. LK received education about insulin use and administration, and hypoglycemia management from the chronic 

care nurse when insulin therapy became necessary.

Services provided by the Native Hawaiian Health 

System

To help manage her diabetes, Ms. LK enrolled in the 

Native Hawaiian Health System remote monitoring 

program. As part of the program, a community 

health worker visited Ms. LK at home and delivered 

a blue tooth-enabled blood glucose (BG) meter and 

blood pressure (BP) cuff for BG and BP monitoring, 

demonstrated how to transmit the BG and BP readings 

after each reading, and uploaded the BG readings to 

the web-based Chronic Disease Management Program. 

Shortly after the upload, Ms. LK received a text message 

from her health care team thanking her for enrolling in 

the monitoring program. The community health worker 

referred Ms. LK and her daughter to the local public 

library for training to access her online portal and view 

her personal health record. The program donated a 

computer to the library in exchange for the librarian 

training of patients and patients’ use of the computer. 

Other aspects of the Chronic Disease Management 

Program include an educational library, patient alerts, 

email consultation, nutritional survey and assessment, 

behavioral health risk survey, electronic health record 

interface with the community health center, remote home 

monitoring, and a complete care plan. The program also 

conducts medication reconciliation to ensure that the 

patient is taking only currently prescribed medications 

and dosages.

Communication

The secure web-based Chronic Disease Management 

Program enabled the patient and the community health 

worker to communicate with the community health 

center physician and chronic care nurse. Ms. LK 

uploaded BG and BP readings for their review and 

received their instructions for adjusting her medication 

doses. 

The community health worker recorded the findings 

of her patient visits for the community health center 

physician and chronic care nurse to review and to convey 

further instructions as necessary. The patient and other 

team members also conducted secure email consultations 

with an endocrinologist located on the Island of Oahu. 

The community pharmacist who refilled Ms. LK’s medications was able to help her understand why she needed 

insulin. 

Insurance coverage

In the current traditional payment system, the e-health 

activities and the outreach worker’s time are not covered. 

The Community Health Center and the Native Hawaiian 

Healthcare System are compensated for “enabling 

services,” making the e-health system a covered service. 

In the future, coverage will be through the management 

fee for the Medical Home Model or covered through an 

Accountable Care Organization Model* with a single 

payment to a larger organization that has an integrated 

delivery system. Kaiser Permanente currently uses many 

of the components of this system to reduce cost and 

improve access. 

Outcomes

Ms. LK’s insulin was effectively adjusted, and she 

took her BP medication daily. Her improved BG and 

BP values were recognized by the web application, and 

she received supportive text messages recognizing her 

improved diabetes management. The community health 

worker visited her every two weeks. Ms. LK visited the 

community health center physician and chronic care 

nurse every three months. Between visits, they were in 

touch via email. As a result of the telehealth support, 

face-to-face visit time focused on reviewing and setting 

self-management goals and discussing the support 

she needed to achieve her goals. Ms. LK took more 

responsibility for her diabetes self-management. Her selfmonitored BG, A1C, and BP values improved. 

*The Accountable Care Organization Model encourages 

physicians and hospitals to integrate care by holding 

them jointly responsible for Medicare quality and costs.
Redesigning the Health Care Team 16 

Other telehealth programs

These programs provide a sample of possible uses of 

telehealth to expand the team care concept. 

The Arizona Diabetes Virtual Center of Excellence 

(ADVICE) is a comprehensive program for diabetes 

prevention, assessment, and management, carried out 

via Arizona Telemedicine Program Network.[46] The 

ADVICE program primarily provides diabetes education 

and individual telenutrition consultations in Spanish and 

English for Hispanics and American Indians who have 

inadequate access to health care. 

The Indian Health Service is expanding its use of telemedicine to bring primary care and specialty medicine to 

remote locations to reduce geographic barriers between 

remote, smaller communities and health care professionals (see IHS resources).

Veterans Rural Health Resource Centers, opened by 

the Department of Veterans Health Administration in 

Vermont, Iowa, and Utah, are finding out how best to 

extend telehealth services to veterans living in rural areas 

(see Veterans Affairs Resources). 

Case Study 2: Florida Initiative in 

Telehealth and Education for Children 

with Diabetes

Toree Malasanos, M.D.

This program was administered by the Florida 

Department of Health, Children’s Medical Services 

Network (CMSN), to integrate telemedicine clinical 

care, web-based education for children with diabetes, 

and virtual home-based behavioral modification. The 

program has served about 99 children and their families 

(44 with diabetes and 55 with other endocrine disorders) 

in Volusia and Flagler Counties since 2001. 

Targeted telemedicine patients were characterized by 

low socioeconomic status, inadequate health insurance, 

poor access to care, poor understanding of the diabetes 

disease process, transient lifestyles, residence in an area 

without access to a pediatric endocrinology specialist, 

and overall low health literacy. The program addressed 

several problems encountered in the pediatric endocrine 

and diabetes clinic:

•	 poor access to care for children with chronic health 

care needs in remote locations 

•	 poor payment and minimal time for diabetes education 

•	 high use of urgent care for recurrent problems rather 

than home management

•	 poor diabetes management and a high hospitalization 

rate 

Services: Telemedicine clinical care

Patients were seen initially and then annually in person 

by the pediatric endocrinologist located in Gainesville, 

at the University of Florida. A teleconference clinic was 

held bi-weekly for an average of 12 families per session. 

Nurses in the remote clinic downloaded meter data, 

obtained a focused history, made basic physical observations, and transmitted the information to the endocrinologist in Gainesville. The pediatric endocrinologist then 

participated in patient interviews and examinations via 

real-time teleconferencing. Families were educated 

during the telemedicine visits and by the website about 

sick-day management and reasons to call the health 

care team. Families were supported in diabetes self-care 

by 24-hour telephone access to the endocrine team in 

Gainesville. Initial patient education was provided by a 

combination of “hands-on” education in Gainesville and 

the web education program. New guardians, families, 

teachers, and school nurses were invited to participate in 

the web education program, called Brainfood.

Services: Home-based behavior change

This statewide home-based virtual program replaced a 

model residential hospital unit with more than 20 years 

experience treating adolescents who had poor adherence, 

frequent hospitalizations, and impaired family dynamics. 

Families involved in the home-based program received 

three to five provider-initiated calls per week to encourage good diabetes self-management by addressing their 

individual barriers to care. Keys to the success of this 

program were a carefully designed curriculum based on 

the former residential program and provision of providerinitiated rather than family-initiated calls.

Web-based diabetes education (Brainfood) 

This was an animated, multiple-literacy presentation 

of diabetes information (including material for nonreaders), with pre- and post-testing. Children with newly 

diagnosed diabetes were given abbreviated in-person 

education at the University of Florida, which was then 

supplemented with Brainfood. Currently, this program is 

available at www.myHealth-e.com. It has been shown to 

increase knowledge about diabetes and its management.

Team members

Children with diabetes and their families worked as 

a team with the CMSN registered nurses, the pediatric 

endocrinologist, University of Florida registered nurses, a 

social worker and a nutritionist based at the remote clinic, 

and school nurses. A psychologist was part of the team 

for the home-based care. Continued on next page.
17 Redesigning the Health Care Team

Payment for services

The program was funded by a contract with the Florida 

Department of Health, CMSN. Medicaid granted a 

waiver for limited coverage of telemedicine services for 

children with special health care needs in under-served 

regions of Florida. A contract between the University of 

Florida and the CMSN provided funds for data management and research, unreimbursed medical costs including 

physician time, phone management for blood glucose 

control between visits, and the home-based behaviorchange program. This program was limited to CMSN 

and Medicaid clients; however, in states in which reimbursement for telemedicine services is allowed, private 

insurers typically follow the same pattern. (Medicaid 

reimbursement by state is described at http://www.ichp.

ufl.edu/documents/Telemedicine in Medicaid and Title V 

Report.pdf.)

Outcomes

Hospitalizations and urgent care utilization: For the 

three years before inception of the program, there were 

on average, 13 hospitalizations per year (47 days) for 

the total group, which subsequently decreased by 88 

percent to 3.5 hospitalizations per year (5.5 days) over 

the two years this was formally evaluated. Emergency 

department visits for the total group decreased from 8 

per year to 2.5 per year. On numerous occasions, ketosis 

was managed by telephone intervention alone, relying on 

family-initiated calls. 

Clinical measures: The mean interval between appointments was reduced from 149 days before the program 

began to 89–91 days over the two years this was formally 

evaluated. Of the children who had an A1C > 8 percent 

when they entered the program, the A1C dropped from a 

mean of 9.63 percent to 8.94 percent, p =.02. Of the children who had an A1C less than 8 percent at their entry 

into the program, 100 percent stayed below 8 percent. 

After two years, the average A1C for all the children was 

8.79 percent. Nineteen of 23 children received the recommended annual dilated eye examination.

Costs: Even when line charges and equipment of 

$18,826 were included, this program saved $27,860 

per year, by reducing hospital days ($44,419/year) and 

emergency department visits ($2,267/year). This does not 

include transportation costs and work/school time saved. 

An additional savings of $64,978 could be considered 

if Medicaid transportation costs were included in the 

absence of the telemedicine clinic. 

Satisfaction with the telemedicine clinic: A survey of 

the 99 program patients (diabetes, 44; other endocrine 

disorders, 55) and their parents found high levels of satisfaction with the program.

Related references

Bell JA, Patel B, Malasanos T: Knowledge improvement 

with web-based diabetes education program: Brainfood. 

Diabetes Technol Ther 2006; 8(4):4444–8.

Adkins JW, Storch EA, Lewin AB, et al.: Home-based 

behavioral health intervention: Use of a telehealth model 

to address poor adherence to type-1 diabetes medical 

regimens. Telemed J E Health 2006; 12(3):370–1. 

Malasanos TH, Patel BD, Klein J, et al.: School nurse, 

family, and provider connectivity in the FITE diabetes 

project. Telemed Telecare 2005;11 Suppl 1:76–8. 

Malasanos TH, Burlingame JB, Youngblade L, et al.: 

Improved access to subspecialist diabetes care by telemedicine: cost savings and care measures in the first two 

years of the FITE diabetes project. J Telemed Telecare 

2005;11 Suppl 1:74–6.

Case Study 2: Florida Initiative in 

Telehealth and Education for Children 

with Diabetes Continued from page 16

Florida has a state-funded telehealth program that 

provides diabetes care to pediatric patients who live 

in Daytona Beach and the surrounding areas and are 

insured through state and federal programs. At the time 

of a clinic visit, an on-site registered nurse obtains a 

standardized patient history, downloads the patient’s 

blood glucose meter data, and faxes the information to 

the University of Florida, Gainesville, pediatric team. The 

nurse also arranges appointments with other providers 

such as a dietitian, a psychologist, or an ophthalmologist 

(see Case Study 2).
Redesigning the Health Care Team 18 

Shared medical appointments and group 

education

A method to increase practice efficiency is shared medical appointments, where a multi-disciplinary team sees 

a group of patients. This model of care is a response to 

factors that include the increasing prevalence of chronic 

diseases such as obesity and diabetes, an aging population with a greater number of complex needs, the need 

to include family members in disease management and 

education, and limitations of the short traditional office 

visit.[47]

Structure and setting

Usually eight to ten patients participate every three 

months in a one- to two-hour appointment, although 

20 or more patients can be seen in longer sessions.[48] 

Successful shared medical appointments for people with 

diabetes have been reported in various settings:

•	 health maintenance organizations[47, 49]

•	 a Veterans Health Administration (VHA) primary care 

clinic at a tertiary care academic medical center[48]

•	 a hospital-based secondary care diabetes unit[50]

•	 an adult primary care center serving uninsured or 

inadequately insured patients[51] 

Interventions

Interventions usually focus on diabetes self-management 

support. Time is included for patients to meet individually with the primary care provider for evaluation of new 

medical problems, medication adjustments, and yearly 

checks for complications. Teams usually include two 

or more health care professionals, as needed, such as a 

family physician, clinical nurse specialist, nurse educator, 

NP, pharmacist, clinical health psychologist, dietitian, 

and podiatrist. Some of the health care professionals are 

certified diabetes educators (CDEs). Other care providers, 

such as eye specialists and dental professionals, could 

also be included. (See Appendix 2 for information on the 

role of CDEs.) 

Evaluation

Success of the group visit model depends on

•	 skilled use of social and facilitation techniques by the 

health care team

•	 identification and scheduling of appropriate patients 

using a patient registry

•	 interpersonal sharing between patients

•	 training support staff

•	 active participation by all stakeholders[47] 

A meta-analysis of randomized controlled and controlled 

clinical studies of group education programs for adults 

with type 2 diabetes was compared with routine care, 

wait list control, or no intervention.[52] Studies were 

included if the intervention was at least one session with 

a minimum of six participants and if the length of followup was at least six months. Fourteen publications describing 11 studies that involved 1,532 participants were 

included. The analysis found significant improvements in

•	 fasting blood glucose levels and A1C

•	 self-care knowledge

•	 systolic blood pressure levels

•	 body weight

Diabetes medication dosage was reduced in one out of 

five participants.[52] 

Other studies of group visits report

•	 fewer hospitalizations and emergency room visits[47, 

49]

•	 improved quality of life[50] 

•	 increased patient satisfaction[47]

•	 lowered cardiovascular risk [48]

•	 weight loss, smoking cessation, increased physical 

activity, and improved depression scores[53] 

(See Case Study 3 on group visits.)
19 Redesigning the Health Care Team

Case Study 3: A Story about Group Visits 

Michael Parchman, M.D. 

Setting

A family physician in San Antonio considered why 

it was so hard for his patients to have optimal control 

of their A1C, BP, and cholesterol. He realized that he 

was trying to pack too much into each visit, and often 

spent 30–45 minutes providing patient education and 

support for some patients. He had previously worked in 

a community health center where group diabetes visits 

were offered, so he decided to conduct a group visit in 

his clinic.

Team members

The team included the physician and his office staff of 

two medical assistants, one licensed vocational nurse, 

three front desk staff, and one lab technician. A local 

representative from a pharmaceutical company was a 

certified diabetes educator and volunteered to teach a 

one-hour class during the group visit. The physician and 

team members held three planning meetings to prepare 

for the group visit. These meetings proved to be essential 

so that team members were prepared and understood 

their roles and responsibilities. 

Services provided

The team selected a Friday morning three months in 

advance for the group visit. As patients with diabetes 

were seen in the clinic over the next three months, those 

with poor control of A1C, BP, or cholesterol were invited 

to attend the group clinic and were given an appointment 

for that Friday morning. 

Each team member was assigned a “station” in each 

of three exam rooms where measures were obtained for 

A1C, LDL-cholesterol, and BP, respectively. The team 

member measured the required value and discussed the 

results with the patient. Each patient was given a station 

visit schedule, ending with a “medication station,” 

where the physician reviewed the patient’s medications; 

reviewed the patient’s A1C, BP, and cholesterol values; 

and then made appropriate changes to the patient’s medications if necessary. 

After visiting all of the stations, the patients gathered in 

the reception area of the clinic for a one-hour discussion 

session with the diabetes educator. A healthy light lunch 

was provided.

Insurance coverage

A one-page template for documentation of the group 

visit was developed for billing purposes. Each staff 

member completed one portion of the template. The 

physician reviewed the documentation and completed the 

template during the one-on-one medication review with 

each patient. The visit with the doctor was billed using 

the usual CPT codes for primary care visits: 99213 or 

99214. 

Outcomes

Of the 20 patients invited, 17 attended. Interviews 

with the physician and office staff after the group visit 

revealed that the staff felt more involved in patient care 

and more satisfied with their role in the clinic than they 

had before the group visit. The physician felt more 

invigorated and was happier with his practice. Both the 

staff and physician reported improved patient understanding and improvements in patients’ diet, physical activity, 

and medication-taking behaviors in the months following 

the group visit. Analysis of data from the charts before 

and after the group visits revealed declines in mean A1C 

from 8.5 to 8.0 percent; systolic BP from 142 to 132, 

and LDL-cholesterol from 124 to 99 mg/dl. Subsequent 

diabetes group visits were held every six months. The 

CDE pharmaceutical company representative continued 

to volunteer and teach a class during the group visits. The 

physician now also holds group clinic visits for patients 

with asthma.
Redesigning the Health Care Team 20 

Payment

One-on-one professional/patient services

Most health care plans pay for physician services 

provided for the management of diabetes. Medicare and 

many private insurance companies and managed care 

organizations pay for 

•	 diabetes self-management education provided by an 

educator who is part of an accredited diabetes education program

•	 diabetes medical nutrition therapy (MNT) provided by 

a registered dietitian

Medicaid coverage for these services varies from state to 

state. 

To receive payment for MNT services provided to a 

Medicare beneficiary with diabetes, a registered dietitian 

must be a Medicare provider and follow specific MNT 

payment rules written by the Centers for Medicare and 

Medicaid Services (CMS) (see Resources under CMS). 

Self-management diabetes education program 

services

To receive Medicare payment for diabetes selfmanagement education services, outpatient diabetes 

education programs must meet defined standards. There 

are currently two organizations that have the authority to 

accredit, or recognize, diabetes education programs: 

•	 American Diabetes Association (ADA)

•	 American Association of Diabetes Educators (AADE) 

(See Resources under ADA and AADE.) 

Recognized diabetes education programs exist in a 

variety of settings, including hospital out-patient clinics, 

physician’s offices, home care agencies, pharmacies, and 

community facilities. 

Recognized programs need to meet all requirements 

developed by CMS for Medicare payment. Diabetes 

self-management education requires a G billing code 

for either individual or group education. (See Resources 

under CMS, AADE, and American Dietetic Association 

for information about Medicare diabetes self-management education and MNT payment provided in a variety 

of practice settings.)

Medicare-covered items

Medicare covers numerous tests, equipment, supplies, 

medications, and services for enrolled people with diabetes and those at risk of diabetes (see Appendix 4). To 

date, most states have passed legislation ensuring varying 

degrees of coverage for the above items for persons 

whose insurance plans are regulated by state law.

Billing practices and CPT codes

To maximize insurance coverage of team member contributions to the patients’ care, it is important to know the 

billing practices in a local area and allowable fees and to 

use the correct CPT codes (see Resources under AACE, 

AADE and AAFP). 

“Incident to” billing

“Incident to” billing can be applied to patients billed 

under Medicare’s traditional fee-for-service system 

for services that are integral although incidental to the 

physician’s personal professional services. Commercial 

payers and some private payers may use a similar billing 

procedure. The “incident to” rules (listed in the Medicare 

Carriers Manual) cover services rendered by other health 

care professionals when the services are

•	 supervised by the physician who is on site at the clinic 

or office at the time of service and who is actively 

involved in the patient’s course of treatment

•	 furnished by a person who is an employee of the 

physician (there may be exemptions)

•	 documented clearly in the medical record

This billing procedure does not apply to MNT or to 

diabetes education services. 

5. Payment and Cost-Effectiveness Data for 

Diabetes Education and Services
21 Redesigning the Health Care Team

Cost-effectiveness evidence for diabetes 

education

Systematic reviews

Summaries of six systematic reviews of diabetes education and related costs emphasize that many studies did 

not include full economic analyses.[54-59] Education 

was provided in a variety of settings and included individual and group education by a variety of health care 

professionals. Although most of the studies indicated 

that diabetes education was likely to be cost-effective, 

a common conclusion of the reviews was that further 

research is needed, including full economic analyses 

and use of well-defined education programs that are 

reproducible.

Observational studies

Two more recent observational studies have concluded 

that diabetes education does result in reduced health 

care costs. One study of 18,404 patients with diabetes 

concluded that any type of diabetes educational visit 

(as opposed to none) was associated with 9.18 fewer 

hospitalizations per 100 person-years and $11,571 less in 

hospital charges per person.[60] Each visit to a nutritionist was associated with 4.7 fewer hospitalizations per 

100 person-years and $6,503 less in hospital charges per 

person. Patients were included in the database if they 

had a diagnosis of diabetes recorded between March 1, 

1993 and December 3, 2001 and at least a one-month 

follow-up period. The mean follow-up period was 4.7 

years. Encounter-form data, including several types of 

education visits from a variety of health care professionals, were linked with hospital discharge data for the same 

period. Some diabetes educators were certified while 

others had either a relevant degree or relevant training 

and experience. 

The second observational study reviewed 482,500 

commercial and 152,000 Medicare claims in payerderived complete three-year data sets for 2005 through 

2007 that were linked with several codes for diabetes 

education services.[61] Commercially insured members 

and Medicare members who participated in diabetes 

education cost on average 5.7 percent and 14 percent 

less, respectively, than members with diabetes who did 

not participate in diabetes education. Diabetes education 

in the commercial group was associated with higher 

use of primary and preventive services and lower use of 

acute, inpatient hospital services. The gap in costs for the 

commercial population between the diabetes education 

and the non-education groups increased over time so that 

by year three, the non-education group average cost was 

12 percent higher. A similar but smaller gap developed in 

the Medicare population’s costs. Claims for Healthcare 

Effectiveness Data and Information Set (HEDIS) diabetes 

process measures were positively correlated with the 

prevalence of diabetes education at the provider practice 

level. Physician referral rates for diabetes education 

varied considerably.

The findings of both of these observational studies imply 

that participating in diabetes education is associated with 

improved clinical outcomes that, in these cases, related to 

fewer hospitalizations or lower overall health care costs.

Guide to develop a business case

A handbook produced by the Diabetes Initiative of the 

National Program Office at Washington University 

School of Medicine provides a guide for diabetes 

education programs to develop a business case for the 

cost-effectiveness of programs, which can be used with 

administrators and payers.[62]
Redesigning the Health Care Team 22 

These examples are a selection of relatively recent studies that, in combination, show the diversity of team care 

in practice. The studies measure different endpoints, 

and few measure improved patient morbidity. They 

do, however, provide practical examples of collaborative care for diabetes prevention and management in a 

variety of practice settings with different professional 

team members. The examples are categorized by practice 

setting and health care professional involvement—and 

are in alphabetical order.

Practice Setting

Community settings

Partnerships between health care professionals, community organizations, and community members may help 

widen the reach of diabetes prevention services for 

people at high risk for diabetes, as well as of diabetes 

management programs. 

The Building Community Supports for Diabetes Care 

program of the Robert Wood Johnson Foundation 

Diabetes Initiative works through clinic-community 

partnerships. Several projects demonstrate how various 

clinic-community partnerships promote diabetes selfmanagement better than any organization could do so 

alone. They are also real-world examples for the community involvement element of the chronic care model.[63] 

Diabetes prevention in adults

In people at risk of developing diabetes with modifiable 

risk factors, low-cost, intensive lifestyle interventions 

delivered at YMCA facilities to modify eating and 

exercise behaviors have thus far shown promising results 

in reducing risk of diabetes. Trained community-based 

fitness instructors were able to deliver an effective groupbased lifestyle intervention in YMCA settings to adults 

at high risk for diabetes.[64] Pilot studies suggest that 

participants achieved weight loss similar to that achieved 

in the original Diabetes Prevention Program. Significant 

changes included decreased body weight and total 

cholesterol maintained over 12 months.[65] 

6. Collaborative Care in Practice

Diabetes prevention in children

A three-armed randomized controlled clinical trial used 

trained extension workers to lead group sessions over 

16 weeks for 93 overweight or obese children ages 8 

to 14 (who were at risk for diabetes) and their families. 

Families were randomized into a behavioral family-based 

intervention, a behavioral parent-only intervention, or 

a wait-list control group. At the 10-month follow-up, 

children in both intervention groups had significantly 

greater decreases in body weight compared with the 

control group.[66] A comparison of intervention costs 

showed that the total program costs for the parent-only 

and family interventions were $13,546 and $20,928, 

respectively. Total cost per child for the parent-only and 

family interventions were $521 and $872, respectively. 

The authors concluded that parent-only interventions may 

be cost-effective for pediatric obesity management, especially for families in medically underserved settings.[67] 

Diabetes management

Connecting with community health workers

Trained community health workers are playing an 

increasingly important role in bridging the gap between 

traditional health care systems and needed diabetes health 

care and education in underserved communities. Through 

their understanding of a community’s language, cultural 

beliefs and traditions, and barriers to care, community 

health workers can help health care professionals and 

their patients achieve more effective diabetes prevention 

and management and make better use of the health care 

system.[68] 

(See AADE Resources for a position statement regarding 

the role of community health workers in diabetes care. 

See CDC Resources for a review of the capacities and 

contributions of community health workers; also see 

Case Study 4.) 

Peer support 

There is growing interest in the role of peers as providers of on-going diabetes self-management support. Peer 

support links people living with diabetes who are able to 

share knowledge and experiences. Peer support can take 
Redesigning the Health Care Team

Case Study 4: Using Community Health 

Workers to Improve Quality in Diabetes 

Care 

Jon Liebman, M.S., M.S.N., and 

Dawn Heffernan, M.S.N. 

Setting

Holyoke Health Center (HHC) in Holyoke, 

Massachusetts, has two sites that serve about 20,000 

patients, most of whom are Spanish speaking. More than 

1,700 of the adult patients have diabetes. In 1999, HHC 

adopted an electronic registry to track these patients and 

their clinical data. In 2003, HHC began using the data 

registry to identify patients lost to routine follow-up 

or who were in poor glycemic control and at risk for 

adverse outcomes. 

Team members

Team members included primary care providers, a 

primary nurse, a pharmacist, a diabetes educator, a nutritionist, and medical assistants. In 2003, trained community health workers were added to the diabetes care team 

to engage and support patients who were not succeeding 

in managing their diabetes.

Services

Adults in poor diabetes control were targeted by 

community health workers for phone outreach and, as 

needed, home visits, to assist them to reestablish primary 

medical care. The health workers functioned as a link 

between patients and their physician and other team 

members to help resolve problems and assist patients in 

overcoming barriers to implementing diabetes self-care 

behaviors.

Communication

In addition to team meetings and telephone contact, the 

team members communicated through formalized documentation tools in the medical record, including progress 

notes, in-house referrals, and shared Excel spreadsheets 

to outline the current services and community health 

worker assignments.

Insurance coverage

The initial project, Proyecto Vida Saludable, was 

funded by the Robert Wood Johnson Foundation. Other 

funders have included the Health Resources and Services 

Administration, Massachusetts Department of Public 

Health, Massachusetts Association for the Blind, Blue 

Cross Blue Shield, and Massachusetts Medical Society.

Outcomes

Improvement in two key indicators may partially reflect 

the effects of the interventions. First, the proportion of 

patients with diabetes who had been seen within the 

previous three years but who had not had an appointment 

within the previous year was reduced from 28 percent 

to 6.5 percent. Second, over three years, the average 

A1C was reduced from 8.4 percent to 7.5 percent, and 

the proportion of patients with an A1C >10 percent 

decreased from 18.2 percent to 10.8 percent.

Related reference 

Liebman J, Hefferman D: Quality improvement in 

diabetes care using community health workers. Clinical 

Diabetes 2008; 26(3): 75-76.

many forms: phone calls, text messaging, group meetings, home visits, and shared activities. Peers can provide 

emotional, social, and practical assistance to help others 

manage their diabetes and stay healthy. Peers can help 

others with diabetes to

•	 figure out how to manage diabetes in their daily lives

•	 identify key resources for healthy foods or for physical 

activity

•	 cope with social or emotional barriers 

•	 stay motivated to reach their goals

•	 seek out clinical care as appropriate

•	 stay engaged in diabetes self-care over the long 

term[69]

Receiving social support may contribute to self-efficacy, 

medication adherence, and improved self-reported health 

status. Peers who provide social support may experience 

less depression, heightened self-esteem and self-efficacy, 

and improved quality of life.[69] (See Resources under 

Peer Support.)

23 
Redesigning the Health Care Team 24 

Managed care 

A study of clinical outcomes in a large managed care 

population of adults with diabetes showed that compared 

to usual care, computer-supported care by a dedicated 

health care team appeared to reduce the number of 

hospitalizations and improve measurement rates for A1C, 

urinary protein, and serum lipid. Glycemic control and 

blood pressure control also improved.[70]

In a health maintenance organization’s pediatric diabetes 

self-management program, a nurse case manager and 

a multidisciplinary clinic team provided education and 

counseling to empower families to improve their child’s 

self-management of diabetes. The means of all measures 

of self-management improved, as did parents’ selfefficacy beliefs.[71]

In Arizona, six competing, capitated Medicare managed 

care plans collaborated with a peer review organization to 

improve outpatient diabetes team management for their 

members. One year after baseline measures were taken, 

there was significant improvement in most indicators. 

Mean A1C values fell from 8.9 percent to 7.9 percent; the 

proportion of patients with A1C values <8 percent rose 

from 40 percent to 62 percent; the use of ACE inhibitors 

increased by 69 percent; and the treatment of dyslipidemia improved from 16 percent to 40 percent. There 

was no significant improvement in lipid profiles.[72] 

(See Case Study 5 for an example of team care in a 

managed care setting.)

Multidisciplinary foot care clinics

A number of studies have reported that multidisciplinary foot care programs have successfully reduced 

lower-extremity amputation rates.[73-75] Coordination 

of activities between various disciplines involved in 

diabetes-related foot care—including surgeons, medical specialists, podiatrists, diabetes educators, and 

Case Study 5: A Collaborative Team 

Approach to Managing Diabetes in a 

Clinic Setting 

Roger P. Austin, M.S., R.Ph., C.D.E.

Setting

The Henry Ford Health System in Detroit, Michigan, 

operates four Diabetes Care Centers in outpatient clinic 

facilities geographically distributed across metropolitan 

Detroit.

Team members

Registered nurses, nurse practitioners, and clinical 

pharmacists who are also CDEs, primary care physician 

“champions,” and specialty care physicians of the Henry 

Ford Medical Group.

Services 

The Diabetes Care Centers’ services require referral 

from a physician who is part of the closed medical group 

practice model. Any patient with diagnosed diabetes and 

an A1C >7 percent is eligible for referral. Clinic enrollment is intended for six months and involves frequent 

interaction with the patient via face-to-face visits, telephone, or email. Services include an initial assessment of 

the patient’s major concerns about diabetes self-management and associated self-care behaviors (eating patterns, 

physical activity, medication taking, stress management, 

problem-solving ability, self-monitoring of blood glucose, 

and risk-reduction practices). Patients are screened for 

depression and possible referral for behavioral health 

counseling. Motivational interviewing methods help 

patients actively engage in their disease management. 

Referrals are made as necessary to other Henry Ford 

Medical Group specialists including cardiology, nephrology, neurology, ophthalmology, and podiatry. 

A unique feature of the clinic services is limited, 

delegated, prescriptive authority to the CDE pharmacist 

“coaches” who manage and change the patients’ medications using health system-approved treatment algorithms 

for management of hyperglycemia, dyslipidemia, and 

hypertension. This allows for rapid-cycle progression of 

therapy, as required, to help patients achieve therapeutic 

goals for blood glucose, lipid, and blood pressure. 

Coaches are authorized to order laboratory tests as necessary to help monitor patients’ responses and to adjust 

medications.

Communication

All coach/patient encounters are documented in the 

electronic medical record system. All coach actions and 

notes require physician approval. Telephone and email 

contact enhance clinical decision-making.

Insurance coverage

Diabetes care services receive capitated coverage 

from the health system and certain preferred provider 

organizations.

Outcomes 

Patient satisfaction feedback surveys that are sent to all 

diabetes center enrollees have been uniformly positive. 

The clinical study that evaluated the concept for this 

service showed a clinically significant decrease in A1C 

levels of nearly 1 percent in the study population (unpublished study).
25 Redesigning the Health Care Team

orthotists—appears to be very important for lowering 

amputation rates.[76] (See Case Study 8 for an example 

of team care in a foot care clinic.)

The Veterans Health Administration (VHA) 

The VHA Prevention Amputation Care and Treatment 

Program (PACT) uses a multidisciplinary team approach 

to identify patients at risk for amputation, which include 

those with diabetes, end-stage renal disease, and peripheral vascular disease. Once identified, the program 

provides a mechanism to screen those “at-risk” veterans 

for foot risk factors in primary care clinics, and to 

provide timely and appropriate referral to specialists. The 

foot screening involves the 

•	 use of the 10gm monofilament to screen for loss of 

protective sensation

•	 palpation of pedal pulses to screen for diminished arterial blood flow

•	 inspection for foot deformities that often lead to foot 

ulcers 

The program uses a series of unique databases to provide 

ongoing performance measurements (amputation levels 

and rates and ulcer types and rates, as well as data on 

patient demographics and “at-risk” and “high-risk” foot 

conditions). PACT monitors continuity information 

about clinic visits to primary care and foot care clinics to 

identify those at highest risk who may require additional 

outreach efforts. 

In 2008, the nationwide compliance with the screening 

performance measure for the monofilament testing for 

veterans with diabetes was 88 percent. The amputation 

rates for people with diabetes have declined from 8.5 

per 1,000 in 2001 to 4.2 per 1,000 in 2008 (see Veterans 

Affairs Resources). 

Primary care clinics

A small, rural primary care clinic that included a critical 

access hospital and a 25-provider physician group implemented care practices in 2006 that improved A1C values 

in all patients with type 2 diabetes. The clinic adopted 

practice guidelines with algorithms for care, and a pharmacist and dietitian provided diabetes self-management. 

A diabetes flowchart was used to track care and a registry 

maintained relevant data.[77]

A pilot study with six primary care providers in a rural 

practice introduced a diabetes nurse educator to work 

with the physicians and their patients with diabetes. 

Results showed improvement in patients’ knowledge and 

empowerment, and A1C and HDL values.[78] 

Compared with care provided by the primary care physician alone, a nurse practitioner–physician team improved 

care to patients with hypertension and diabetes. In the 

team-treated group, one-year costs for personnel were 

modestly higher, but participants experienced significant 

improvements in mean A1C and HDL values and in 

satisfaction with care.[79] A primary care physician in a 

large multi-specialty medical group introduced team care 

to his practice and improved quality-of-care indicators 

for patients with diabetes.[80] (See Case Study 6 for an 

example of team care in a primary care setting.) 

Stepped diabetes management 

In stepped care, the team assesses patients’ management 

concerns, skills, and resources and then sets education 

and treatment goals in collaboration with patients. Precise 

timelines are set for success with individual therapies. 

The team provides different steps or levels of treatment 

according to predetermined protocols until management 

goals are met and maintained. Combined evaluation 

data are generated for providers to compare changes 

in practice with baseline measures. This approach was 

tentatively estimated to generate lifetime savings of 

about $27,000 per patient after six to seven years when 

modeled with the costs of acute and chronic complications.[81] More recently, in an academic family practice 

clinic, stepped care resulted in significant cost-neutral 

improvement in A1C values.[82] 

Health Care Professional Involvement

Dental professional team members

Oral health care professionals play an important role as 

part of the health care team by providing oral care to 

patients with or at risk for diabetes. Glycemic control 

may exacerbate periodontal disease and, conversely, 

periodontal disease may cause deterioration of glycemic 

control. Growing evidence supports this bidirectional 

link between periodontal disease and diabetes, but further 

research is needed to understand this relationship. The 

IDF Guideline on Oral Health for People with Diabetes

recommends that diabetes care providers incorporate oral 

health into diabetes education and refer patients to dental 

health professionals annually for oral health care.[83] 

Few studies probe the financial impact of the periodontal 

disease-diabetes relationship. Some research indicates 

increased dental costs for people with diabetes.[84] 

Dentists and dental hygienists can work with the physician, diabetes educator, and dietitian to maintain the 

patient’s oral health and possibly improve the patient’s 

metabolic control of diabetes. New screening tools will 

enable dentists to detect and refer undiagnosed cases 
Redesigning the Health Care Team 26 

of diabetes.[85] Reducing tobacco use via anti-tobacco 

promotion and tobacco-cessation programs could 

improve both cardiovascular health and oral health.[86]

Depression care managers

Older patients with diabetes and depression who received 

team care via the IMPACT program (Improving MoodPromoting Access to Collaborative Treatment for Late 

Life Depression) had an average of 115 more depressionfree days, better physical functioning and quality of life, 

and lower medical costs over two years than did patients 

treated with standard care. The lower costs more than 

offset the cost of the team care. The IMPACT team 

includes a depression care manager (usually a nurse, 

social worker, or psychologist) who works closely with 

the patient’s primary care physician and a consulting 

psychiatrist to treat depression in the patient’s regular 

primary care clinic.[87, 88]

Eye care professionals

Achievement of the Healthy People 2010 objective 

to improve rates of preventive annual dilated eye 

examinations in people with diabetes was assessed in 

59 CDC Diabetes Prevention and Control Programs. 

Results showed that from 2000 to 2003, the aggregate, 

age-adjusted rate of annual dilated eye examinations 

decreased from 67.7 percent to 65.2 percent (P=.05).[89] 

Ophthalmologists and optometrists are critical members 

of the health care team with unique responsibilities for 

diabetes eye health.[90] Implementing recommendations 

for annual dilated eye examinations is essential to help 

prevent vision loss from diabetic retinopathy. 

Case Study 6: Clinica Family Health 

Services: Enhanced Team Functioning 

Carolyn Shepherd, M.D. 

Setting

The Clinica Family Health Services community health 

center provides care to a largely uninsured Hispanic 

population of about 40,000 patients at four sites near 

Denver, Colorado. The health center was one of the first 

to participate in the Health Disparities Collaborative of 

the federal Bureau of Primary Health Care (www.healthdisparities.net) and has worked to improve primary care 

practice since 1999. The center has made major organizational and cultural changes in the process of forming its 

high-functioning teams. 

Team members

Primary care teams are called “pods.” There are four 

pods at one site, two at another, and three pods at each 

of the two other sites. Each pod is color coded to help 

patients identify with their care team and to improve 

continuity of care—the walls and the primary care 

provider business cards and appointment cards are differently colored.

Each pod has three full-time equivalent primary care 

clinicians: physicians, NPs or PAs, and certified nurse 

midwives. Medical assistants usually work with a single 

clinician, contributing to continuity of care. Pods also 

have a nurse team manager, who is either a registered 

nurse (RN) or a licensed practical nurse (LPN). Pods 

share a referral case manager, social worker, office 

manager, and financial screener. The organization has 

a registered dietitian who is a CDE. The dietitian helps 

train RNs and LPNs, supports group visits for people 

with diabetes with their primary care provider, and 

counsels individual patients with diabetes. All clinicians 

and staff who care for patients are required to be 

bilingual Spanish speakers. 

Services

To improve continuity of care, each of the 60 or more 

primary care clinicians has his or her own panel of 1,000 

to 1,200 patients. This panel size maximizes the goal that 

patients see the same clinician whenever possible at each 

visit and has improved access to care. The primary care 

clinicians assess and manage current medical problems 

and comorbid conditions. For chronic diseases such as 

diabetes, computer-generated registries, reminders of 

checks for diabetes management, and status of complications help clinicians provide timely care. 

The referral case managers, often high school graduates 

trained by the center, relieve clinicians of the timeconsuming efforts to arrange appointments and negotiate 

payment for services. Pod case managers help patients set 

self-management goals, do brief screenings for depression, counsel patients with mild to moderate depression, 

and help with tobacco cessation follow-up and referrals. 

Medical assistants take vital signs, document history 

of present illness, screen for tobacco use, room patients, 

draw blood, and do depression screens. Working with 

pod receptionists, they manage the chronic disease registries and order overdue tests. Up-to-date registry data are 

pulled directly from the electronic health record database 

and displayed, using crystal reports and business intelligence tools. 

RNs and LPNs play a central role. They coordinate 

team activities, oversee the medical assistants, and 

provide health education. They activate diabetes patients 

to manage their illness by providing diabetes education 

and seeking patients’ input for goal setting during each 

Continued on next page.
27 Redesigning the Health Care Team

visit. Patients choose their own self-care goals as part 

of their self-management plans. Lessons learned in selfmanagement are then applied by the patient toward other 

health care goals such as walking or stopping tobacco 

use. Under a primary care provider’s supervision, RNs 

and LPNs screen for and treat simple infections, obtain 

urine cultures, and contact patients. 

Communication

Clinical sites are organized so that pod teams work in 

the same open room at the pod’s center, from which they 

can see all the patient rooms. This enables team members 

to easily and quickly communicate with one another. 

Incoming calls are routed to a centralized call center. Calls 

with clinical content go to the pod receptionist, who also 

contacts patients with normal lab results, checks patients 

in and out of their visits, and helps manage chronic 

disease registries. Outgoing calls are generally made by 

the case manager, LPN, or medical assistant, using clinical protocols or specific instructions from the clinician to 

inform patients of abnormal lab results, schedule periodic 

care, schedule patients in group visits with their primary 

care provider, and refill prescriptions. Since most of the 

patients do not have health insurance, the clinic uses a 

digital retinal camera to screen patients and determine 

who needs to be referred for specialty eye care. 

Insurance coverage

More than half of Clinica Family Health Services 

patients do not have any health insurance coverage. 

The cost of care to these patients is supported by a 330 

Federally Qualified Health Center grant. Services to 

patients with diabetes are billed to state Medicaid and 

Medicare when the patient has this coverage. Less than 

eight percent of patients have private insurance. 

Outcomes

Continuity of care with the patient’s primary care clinician is 80 percent for well care, 70 percent for diabetes 

care, and 60 percent for acute care such as asthma 

visits. Access to care is three days or fewer for established 

patients compared to three weeks to three months prior to 

the formation of patient panels, and patients’ no-show rate 

has dropped from 35 percent to eight percent. 

A summary of Clinica Family Health Services’s selfreported data showed that the average A1C level of its 

population (now 1,916 patients) with diabetes dropped 

from 10.5 percent in October 1998 to 7.9 percent in 

November 2009. The percentage of patients with diabetes 

with at least two A1C tests within a year rose from 11 

percent in October 1998 to 92 percent in November 2009. 

The percentage of patients with diabetes self-management 

goals rose from three percent in February 1999 to 50 

percent in November 2009. The percentage of those 

having foot examinations rose from 15 percent to 62 

percent in the same period. Since 2007, these data have 

been pulled from the EMR database and now include 100 

percent of the diabetes population for every measure.

Related references

Shepherd C: Clinica Family Health Services: Using space 

and financial incentives to enhance team functioning. In: 

Bodenheimer T, ed. Building Teams in Primary Care: 

15 Case Studies. Oakland, CA.: California Health Care 

Foundation, 2007; 9-11. 

Bodenheimer T, Wagner EH, Grumbach K: Improving 

primary care for patients with chronic illness. JAMA 

2002; 288(14): 1775-9.

Case Study 6: Clinica Family Health 

Services: Enhanced Team Functioning

Continued from page 26

Efforts to improve coordination among team members 

to facilitate referral for eye examinations can increase 

eye care in low-income, uninsured populations.[91] 

Multidisciplinary patient-centered vision care algorithms 

have been developed to help patients with diabetes to 

access appropriate screening and management of diabetic 

retinopathy.[92] A standard reporting form for eye examination results can be easily used in clinical practice[93] 

(see American Optometric Association resources). A 

comprehensive microvascular complications checklist is 

being developed by the NDEP.

Nurse and dietitian certified diabetes educators

A program to implement and financially sustain an 

effective diabetes self-management education program 

was implemented for patients seen in community hospitals and primary care practices in the western part of 

Pennsylvania.[94] Nurse and dietitian CDEs worked with 

primary care office staff to provide “diabetes day” individual and group patient appointments. Results showed 

increased patient access to these education services, 

improvement in A1C levels, and increased nurse involvement in medication initiation and adjustments, and patient 

satisfaction. Recognition from the American Diabetes 

Association in 21 sites enabled billing practices to help 

cover costs through payment for the educators’ services 

(see Case Study 7).

Pharmacists

By taking nontraditional roles in family practice or 

medicine clinics in both urban and rural communities, 

pharmacists can improve chronic disease management, 
Redesigning the Health Care Team 28 

utilizing education and counseling skills or collaborative 

practice agreements with physicians. 

Pharmacist interventions

A systematic review of 21 published studies of pharmacist interventions with adults with diabetes included 

nine randomized controlled trials, one controlled trial, 

and 11 cohort studies with a control group. Findings 

demonstrated consistent positive effects on patient A1C, 

lipids, and blood pressure values. Many pharmacist-based 

models were used to achieve the outcomes, but those 

with direct pharmacist-patient involvement resulted in the 

greatest A1C reductions (>1 percent decrease). Overall, 

most studies found that involving pharmacists in patient 

education was associated with at least a 0.5 percent 

reduction in A1C, a 17-18 mmHg reduction in blood 

pressure, and an 11 mg/dl reduction in LDL. The review 

authors caution that the findings are limited by flaws in 

study designs, including likely selection bias in the study 

populations. Only a few of the studies examined health 

care resource use. One reported that the average cost to 

lower A1C by 0.5 percent when utilizing a pharmacist 

was about $315 per patient, over approximately seven 

pharmacist visits.[95] 

In a free-standing clinic, a pharmacist-provided program 

provides comprehensive diabetes and medication therapy 

management to the University of Kentucky’s health plan 

members who have diabetes, primarily type 2. A study 

of 263 patients after one year of program participation 

found significant A1C and lipid improvements, increased 

screenings for diabetes complications, and increased 

patient satisfaction with care, compared with baseline.

[96] A fee-for-service system is used.[97] 

The Asheville Project—an employer collaboration

The Asheville Project was first implemented in 1997 

as a pilot community-pharmacy care program, with 46 

diabetes patients covered by two self-insured employers’ health plans. Patients received education by CDEs 

and long-term community pharmacist follow-up using 

scheduled consultations, clinical assessment, goal setting, 

monitoring, and collaborative drug therapy management 

with physicians. Results showed a 50 percent reduction 

in sick days within 14 months that remained consistent 

after 5 years, and zero workers’ compensation claims 

between 1997 and 2003. Mean A1C levels improved, and 

total mean direct medical costs decreased by $1,200 to 

$1,872 per patient per year compared with baseline.[98] 

Case Study 7: Introducing Diabetes 

Education Services in Rural Communities

Gretchen Piatt, Ph.D.

Setting

The key goal of the Healthy People 2010 diabetes focus 

area is to increase the proportion of people with diabetes 

who receive formal diabetes education.1 A common 

challenge in meeting this goal is generating referrals for 

diabetes outpatient education services.2 To address this 

problem, the University of Pittsburgh Diabetes Institute 

(UPDI) implemented the Chronic Care Model3 in a 

number of primary care practices in rural communities 

just outside of Pittsburgh, Pennsylvania.4 The goal was 

to defragment the health system and restructure it to be 

evidence-based, population-based, and patient-centered. 

Team members

Primary care physicians, office staff, and three CDEs 

(2 nurse CDEs and 1 dietitian CDE) are available on 

designated “diabetes days” in each of 17 primary care 

practices. The CDEs rotate to different offices based on 

their schedules.

Services

To increase referrals for education services, the UPDI 

began in 2003 to deliver diabetes self-management 

education (DSME) at the point of service in the primary 

care office setting. The program started with four primary 

care practices and expanded to 17 throughout southwestern Pennsylvania. Decision-support tools, including the 

American Diabetes Association’s (ADA’s) Standards of 

Medical Care in Diabetes5 and the National Standards 

for Diabetes Self-Management Education6 were used by 

team members to provide consistent care and benchmarking to allow for clinical evaluation efforts. All DSME 

sessions used an empowerment approach to diabetes 

education, and clinical and behavioral outcomes were 

collected for each patient. 

Communication

The CDEs met with the local practice physicians 

and their office staff to determine the best methods for 

communication and documentation within the practice 

and to arrange their appointment schedule. 

Insurance coverage

Previous efforts have established that payment for 

DSME is critical in generating revenue to support the 

services of CDEs. In this setting, the CDEs secured 

ADA recognition for each of the 17 primary care sites 

and were then able to bill for their services in the primary 

care setting. 

Continued on next page.
29 Redesigning the Health Care Team

Outcomes

Individuals who received DSME, both at the point of 

service and in traditional outpatient education settings 

experienced significant decreases in mean A1C levels 

over time (point of service DSME: 7.6 percent to 7.3 

percent, p<0.0001; traditional DSME: 7.0 percent to 6.7 

percent, p<0.0001); however, it must be noted that those 

who were referred to point-of-service DSME had higher 

baseline A1C values and may have represented people 

who needed more-specialized attention. The same pattern 

was observed in LDL-cholesterol levels. Individuals who 

received DSME at the point of service had significant 

declines in LDL (118 mg/dl to 101 mg/dl, p<0.0001). 

This decline was larger than was observed in individuals 

who received traditional outpatient DSME (116 mg/dl to 

107 mg/dl, p<0.0001).

Related references 

1.U.S. Department of Health and Human Services: 

Healthy People 2010. Washington D.C. U.S. 

Government Printing Office, 2000.

2.Balamurugan A, Rivera M., Jack L, Allen K, Morris 

S: Barriers to diabetes self-management education 

programs in underserved rural Arkansas: implications 

for program evaluation. Preventing Chronic Disease 

2006; 3:1–8.

3.Wagner EH, Austin BT, Von Korff M: Organizing care 

for patients with chronic illness. Millbank Quarterly 

1996; 74:511–544.

4.Siminerio, LM, Piatt GA, Emerson S, et al.: Deploying 

the chronic care model to implement and sustain diabetes self-management training programs. The Diabetes 

Educator 2006; 32(2): 253-60. 

5.American Diabetes Association: Standards of medical 

care in diabetes–2011. Diabetes Care 2011; 34(Suppl 

1): S11–61. 

6.Funnell MM, Brown TL, Childs BP, et al.: National 

standards for diabetes self-management education. 

Diabetes Care 2007; 30(6): 1630–7.

Case Study 7: Introducing Diabetes 

Education Services in Rural Communities

Continued from page 28

Today, more than 1,000 patients from five employers are 

enrolled for diabetes, asthma, and hypertension and lipid 

therapy management through the Asheville Project. 

The Diabetes Ten City Challenge—an employer 

collaboration 

Based on the Asheville Project model, the American 

Pharmacists Association (APhA) Foundation offers 

a non-profit consulting service under its Patient SelfManagement Program for Diabetes, to help employers 

organize and implement diabetes management programs. 

The Diabetes Ten City Challenge is the latest initiative 

of the program in which participating employers offered 

a health care plan that waived co-payments for diabetes 

medications and supplies if patients worked with a pharmacist “coach” to monitor and manage their condition. 

In ten cities, thirty employers, hundreds of local pharmacists, and more than 800 people with diabetes participated 

in the initiative. 

Results were reported for 573 patients with diabetes who 

had baseline and year-one medical and pharmacy claims 

and two or more documented visits with pharmacists. 

Statistically significant improvements were observed for 

key clinical measures, including A1C, LDL cholesterol, 

and mean systolic blood pressure. The rate of flu vaccinations and foot and eye exams increased. Employers realized an average annual savings of almost $1,100 in total 

health care costs per patient when compared to projected 

costs if the study had not been implemented, and participants saved an average of almost $600 per year.[99] 

Podiatrists

Recent examples of successful multidisciplinary lowerextremity screening, prevention, and treatment programs 

for diabetes foot disease have been reported for managed 

care and a large military medical center.[73, 100] These 

programs significantly reduced amputation rates and footrelated hospital admissions. Teams involved podiatrists, 

vascular specialists, and other health care professionals. 

Podiatrists and vascular surgeons play key roles in 

interdisciplinary lower-limb preservation teams that have 

significantly improved patient outcomes and reduced 

amputation rates in people with diabetes.[101, 102] Other 

team members may include trained physicians, primary 

care providers, nurses, footwear specialists, and others 

as necessary. Essential skills for these teams include 

assessment of the patient’s vascular, neurological, and 

wound status; collection of soft tissue cultures and bone 
Redesigning the Health Care Team 30 

Case Study 8: A Podiatric Limb 

Preservation Team in Action

Vickie R. Driver, D.P.M.

Setting

The Limb Preservation Service at Madigan Army 

Medical Center in Tacoma, Washington, began as a 

“foot-at-risk” clinic in the Department of Podiatry. Over 

time, the foot-at-risk clinic specialized in the management of diabetes-related foot disease and became the 

Limb Preservation Service that provides both inpatient 

and outpatient services. The medical center is a 172-bed 

military regional tertiary care hospital with a beneficiary 

population of about 350,000. Madigan is one of three 

designated Level 2 trauma centers in the U.S. Medical 

Command.

Team members

The Limb Preservation Service is headed by the 

podiatry department. Clinic podiatrists conduct the first 

evaluation of patients with diabetes, assess risk factors, 

and manage foot ulcers and emergency treatment of foot 

infections. Vascular surgeons participate in the management of critical limb ischemia and peripheral arterial 

disease. A specialized wound care nurse assists the physician in carrying out wound care treatment plans. She or 

he also works independently as a wound care provider. A 

pedorthist provides customized shoe and orthotic devices.

Services

Regular care of the foot in patients with diabetes 

depends on the severity of their condition and the 

presence of risk factors. Patients followed by the limb 

preservation team received comprehensive inpatient and 

outpatient care that includes 

•	 state-of-the-art advanced wound care management

•	 medical and surgical management of infection

•	 at least a quarterly clinic visit (the frequency of the 

visits depends on the severity of the problem)

•	 ongoing education that includes families 

•	 orthotic devices, extra-depth shoes, and custommade 

shoes as needed

Patient education is a high priority and is usually 

provided by a podiatrist or wound care nurse during 

both inpatient and outpatient visits. An individualized 

education plan is part of the electronic medical record. 

The higher the risk for limb loss, the more intensive the 

educational program.

Communication

Electronic medical records are used. Team members 

consult in person to discuss the most complex cases. 

Since it is an army medical center, specialist referrals are 

easily made and recommendations incorporated into the 

medical record. Two important factors contribute to the 

success of the limb preservation service: close collaboration among team members, and the fact that the patients 

remain within the military hospital system for a long 

period of time. 

Insurance coverage

Patients pay for their care through TRICARE, the 

single-payer health care program of the United States 

Department of Defense Military Health System. 

Outcomes

From the beginning of the Limb Preservation Service in 

1999 to 2003, the rate of non-traumatic lower extremity 

amputations decreased significantly despite the increase 

in the overall population of patients with diabetes who 

were referred to the service. 

Data were then collected on a random sample of 

485 patients among the 8,422 patients with diabetes 

followed at the medical center between June 1999 and 

June 2004. Patients were stratified according to the 

University of Texas classification system that classifies 

diabetic wounds based on risk and severity and divided 

in two groups: those followed by the Limb Preservation 

Service and those followed by a non-specialized service. 

Over the five-year period, patients referred to the Limb 

Preservation Service had more severe disease than 

patients who were receiving non-specialized services. 

This resulted in a higher proportion of minor amputations 

in the Limb Preservation Service group but no significant 

increase in major amputations. Continued on next page.

biopsy; wound incision and debridement; initiation and 

modification of antibiotic therapy; and active monitoring of the healing phase. A hospital-based setting where 

such centers can provide both outpatient and inpatient 

care helps maintain a financially viable program.[103] A 

comprehensive microvascular complications checklist is 

being developed by the NDEP. (See NDEP Resources 

and Case Study 8.)

Registered dietitians

A one-year randomized controlled trial compared 

usual medical care to usual care-plus-lifestyle case 

management provided by a registered dietitian. The 

case-managed group showed substantially greater weight 

loss, reduced A1C values, decreased prescription use, 

and increased health-related quality of life.[104] Case 

management participants had fewer inpatient admissions, which substantially lowered medical care costs. 
31 Redesigning the Health Care Team

There is evidence that a team approach can reduce risk 

factors for type 2 diabetes, improve diabetes management, and lower the risk for chronic complications. 

This evidence supports an opportunity for health care 

professionals and organization leaders to help improve 

the health of people with diabetes. At the same time, it 

is important that studies of team interventions involving 

the skills of numerous health care professionals continue 

to elucidate effective ways to implement team care that 

improve patients’ well-being and to assess the costs 

involved. 

The commitment of an organization’s leadership is 

essential for a team to provide comprehensive, lifetime management for patients with diabetes. Team 

care requires a collaborative, interactive, multi-skilled 

approach that maximizes the use of many different health 

professionals as educators, care coordinators, and providers of services to help patients achieve the best health 

outcomes possible. Community health workers, innovative interactions via telehealth technology, and alternative 

ways to deliver care such as group visits all contribute 

to the practice of team care. When patients participate 

as decision-making partners in care, improved diabetes 

control can be achieved. This improvement, in turn can, 

lead to greater patient satisfaction with care, better quality 

of life, improved health outcomes, and lower health care 

costs. Team care is likely to play a major role in future 

health care systems designed to provide comprehensive 

lifetime prevention and management of chronic diseases 

such as diabetes.

7. Summary

Related references

Driver VR, Goodman RA, Fabbi M, et al.: The impact 

of a podiatric lead limb preservation team on disease 

outcomes and risk prediction in the diabetic lower 

extremity: a retrospective cohort study. J Am Podiatr 

Med Assoc 2010; 100(4): 235-41.

Driver VR: Reducing amputation rates in patients with 

diabetes in a military medical center. Diabetes Care 

2005; 28(2): 248-53.

Case Study 8: A Podiatric Limb 

Preservation Team in Action

Continued from page 30

Providing medical nutrition therapy to high-risk patients 

with type 2 diabetes and obesity decreased health plan 

costs by 34 percent.[105]

Registered nurses 

With medical direction and defined protocols, nurses 

can make clinical management decisions about the treatment of diabetes, lipids, and hypertension; provide selfmanagement education; and coordinate team services to 

meet the patient’s health care needs. Compared to usual 

physician care, nurse-directed diabetes care for minority 

adults improved process measures 98 percent of the time 

compared to 54 percent; A1C levels decreased to 

7 percent compared to 8.7 percent and 82 percent of 

patients met the LDL goal of <100mg/dl compared to 51 

percent.[33] 

One study evaluated the introduction of nurse case 

managers to collaborate at the office level with 

community-based primary care physicians in the care 

of 197 adult patients with type 2 diabetes. After six 

months, patients who received individual counseling, 

problem identification, care planning, and management 

recommendations from the nurse case manager had 

significantly improved mean systolic blood pressure and 

A1C values.[106] 

A self-management program with a nurse case manager 

for children with diabetes showed improved A1C values, 

quality of life, and self-efficacy.[71] The frequency of 

nurse case manager follow-up contacts appears to be 

positively linked to better patient A1C values.[107] 
Redesigning the Health Care Team 32 

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 complications may require the lowest intensity of 

care and resources, whereas those with complications 

or comorbidities or those who are at break points in 

their disease management may require more-intensive 

services. 

A. Identify patients at risk for type 2 

diabetes

Risk factors for type 2 diabetes[40] include 

•	 Overweight adult: Body Mass Index ≥25 kg/m2 (≥23

if Asian American or ≥26 if Pacific Islander) with one

or more of the following

•	 Family history: has a first-degree relative with diabetes 

•	 Race/Ethnicity: African American, Hispanic/

Latino, American Indian and Alaska Native, or Asian 

American and Pacific Islander

•	 History of gestational diabetes or gave birth to a baby 

weighing > 9 lbs 

•	 Hypertension: blood pressure >140/90 

•	 Abnormal lipid levels: HDL cholesterol level 

<35mg/dl; triglyceride level >250 mg/dl 

•	 IGT or IFG: on previous testing 

•	 Signs of insulin resistance: such as acanthosis nigricans or polycystic ovarian syndrome (PCOS)

•	 History of vascular disease: diagnosed by physical 

exam and testing

•	 Inactive lifestyle: is physically active less than three 

times a week

In the absence of the above risk factors, people age 45 

and older are considered at risk and should be tested at 

least at three-year intervals.

Appendix 1: Stratifying Care According to 

Patient Population Needs

B. Identify patients at risk for diabetes 

complications

Identifying patients at risk for diabetes complications 

can help the team to effectively stratify services. Clinical 

information to assess risk includes

•	 A1C values

•	 blood pressure control

•	 lipid control

•	 cardiovascular disease risk

•	 eye disease risk

•	 foot disease risk

•	 evidence of increased urinary albumin excretion and/

or reduced eGFR

•	 smoking habits

•	 alcohol use

•	 family history of diabetes complications including 

premature cardiovascular disease

•	 duration of the disease

•	 oral exam status

•	 hypoglycemia history

•	 depression and other psychosocial illness

•	 reduced literacy

•	 inadequate social support

Patients with type 2 diabetes who are largely free of 

diabetes complications or other comorbidities will benefit 

from relatively low-cost preventive care focused on risk 

factor reduction and health promotion. After screening 

for complications, the team could offer group discussions 

about risk factor reduction and self-management issues 

such as nutrition, weight management, and ways to incorporate regular physical activity into lifestyles. 
33 Redesigning the Health Care Team

C. Identify patients with complications and 

other comorbidities

Identifying the patients who have diabetes complications 

or other comorbidities can help determine those who 

will require more extensive resources, such as allocation 

of additional team members, more aggressive protocol 

management, or more frequent follow-up.[108, 109] 

Analyses of administrative databases have demonstrated 

that a large fraction of health care dollars are allocated to 

a small proportion of the population with multiple comorbidities. It is important to note, however, that patients 

with complications are an evolving group and that for 

practical planning purposes, periodic reassessment is 

essential.

D. Identify patients at “break points”

To predict other potential high resource users, identifying 

patients at “break points” in the course of their disease 

may be helpful. These points include

•	 new onset of type 1 or type 2 diabetes

•	 A1C consistently above 8 percent

•	 new onset of significant complications

•	 frequent or severe hypoglycemia

•	 pregnancy in a woman with diabetes

•	 initiation of insulin therapy[27]

Assessing reasons for consistently elevated A1C values 

in the patient population also may help team planning. 

The level of diabetes control can be affected by several 

factors

•	 limited provider availability and service payment

•	 outdated or ineffective management protocols

•	 limited medical and dental insurance coverage for 

patients

•	 limited insurance coverage for medications or supplies

•	 cognitive, psychological, and social barriers that limit 

patient participation in diabetes management

•	 limited diabetes self-management education or selfmanagement support
Redesigning the Health Care Team 34 

A. Guidelines and Competencies

Guidelines for the Practice of Diabetes Education delineates the roles and responsibilities for individuals and 

organizations involved in the facilitation and delivery of 

diabetes education and care for persons with or at risk for 

diabetes and their families/caregivers. 

http://www.diabeteseducator.org/DiabetesEducation/position/Practice_Guidelines.html

Competencies for Diabetes Educators provides a master 

list of the knowledge and skills needed for the various 

levels of practice. They are the basis for education, training, development, and performance appraisal of all clinicians engaged in diabetes education. 

http://www.diabeteseducator.org/export/sites/aade/_

resources/pdf/competencies.pdf

B. The Role of Diabetes Educators

Diabetes educators help people with and at risk for diabetes and related conditions to achieve behavior-change 

goals that lead to better clinical outcomes and improved 

health status. Diabetes educators apply in-depth knowledge and skills in the biological and social sciences, 

communication, counseling, and education to provide 

self-management education and training. 

http://www.diabeteseducator.org/export/sites/aade/_

resources/pdf/Definition_Diabetes_Educator.pdf

Certified Diabetes Educators (CDE) receive certification from the National Certification Board for Diabetes 

Educators by taking a voluntary examination that 

indicates distinct and specialized knowledge in diabetes 

patient self-management education, thereby promoting 

high-quality care for people with diabetes. Objectives of 

the certification program are to

•	 provide a mechanism to demonstrate professional 

accomplishment and growth 

Appendix 2: Scope of Practice for Diabetes 

Educators and Board-Certified Advanced 

Diabetes Management Practitioners

•	 provide formal recognition of specialty practice and 

knowledge at a mastery level 

•	 provide validation of dedication to diabetes education 

to consumers and employers

•	 promote continuing commitment to best practices, 

current standards, and knowledge 

www.ncbde.org

Certification can be awarded to those who meet eligibility requirements and are from the following disciplines: 

registered dietitian, exercise physiologist, health educator, registered nurse, nutritionist, occupational therapist, 

optometrist, pharmacist, physical therapist, physician 

(M.D. or D.O.), physician assistant, podiatrist, public 

health professional, clinical psychologist, or social 

worker. 

www.ncbde.org/eligibility.cfm

C. The Role of Board-Certified Advanced 

Diabetes Management (BC-ADM) 

Practitioners

The Board-Certified Advanced Diabetes Manager 

(BC-ADM) credential was developed to verify clinical 

care skills among advanced practitioners. The BC-ADM 

credential is a multidisciplinary credential for nurses, 

dietitians, and pharmacists who have advanced degrees. 

It is different from the CDE credential in that it focuses 

on advanced clinical management of diabetes. The exam 

covers the domains of clinical practice, collaboration, 

research, patient and professional diabetes education, and 

public and community health. 

www.diabeteseducator.org/ProfessionalResources/

Certification/BC-ADM/

http://www.nursecredentialing.org/Certification.aspx
35 Redesigning the Health Care Team

The increasing demand for high-quality care from 

managed health care systems, payers, and the public 

is an important development. The Diabetes Quality 

Improvement Project was an initial national collaborative 

effort to improve diabetes care and the quality of life for 

people with diabetes, consisting of eight performance 

measures for diabetes care that cover A1C and lipid 

testing and assessment of the eyes, kidneys, and feet. 

Numerous public agencies (the Department of Defense, 

the Health Care Financing Administration, multiple state 

Medicaid programs, the Indian Health Service, and the 

Veterans Health Administration) and private groups (the 

National Committee for Quality Assurance, NCQA) have 

developed quality measures in comprehensive diabetes 

care. 

Diabetes performance measures have been incorporated 

into NCQA’s HEDIS* measures; these are reported 

publicly for Medicare, Medicaid, and commercial and 

managed care plans that serve Medicare beneficiaries. 

The Diabetes Recognition Program (DRP) administered 

by NCQA, is a voluntary recognition program for physicians and nurse practitioners who demonstrate high-quality outpatient diabetes care. A number of the processes 

and outcomes measured in the DRP could readily involve 

team care (see www.ncqa.org). 

Appendix 3: Quality Improvement 

Indicators for Diabetes Care

Diabetes HEDIS measures for care, screening, or testing 

needed for comprehensive diabetes care for adults ages 

18 to 75, consist of the following

•	 A1C testing twice a year

•	 A1C result > 9% = poor control measure

•	 A1C < 8%

•	 A1C result < 7% = good control measure

•	 LDL-C measurement 

•	 LDL-C result < 100

•	 retinal eye exam

•	 nephropathy screening test or evidence of 

nephropathy

•	 blood pressure < 140/90

•	 blood pressure < 130/80 

*Healthcare Effectiveness Data and Information Set 
Redesigning the Health Care Team 36 

What Is Medicare?

Medicare is health insurance for people age 65 or older, 

under age 65 with certain disabilities, and any age with 

end-stage renal disease (permanent kidney failure requiring dialysis or a kidney transplant). People with diabetes 

who are eligible for Medicare can get the most from their 

Medicare benefits by learning about the types of services 

that are available. People with diabetes are encouraged to 

ask their health care team about the benefits they qualify 

for and visit www.medicare.gov to get specific details 

from Medicare.

What Benefits Does Medicare Offer for 

People with Diabetes?

People with diabetes enrolled in Medicare may be 

covered for all or part of the cost for 

•	 a “Welcome to Medicare” physical exam when they 

enroll 

•	 A1C testing

•	 cholesterol testing 

•	 diabetes self-management training to learn how to 

manage diabetes 

•	 medical nutrition therapy: nutrition and lifestyle 

assessments, diet management information, and nutrition counseling 

•	 diabetes equipment and supplies for self-monitoring of 

blood glucose, including special equipment for persons 

with low vision

•	 foot exams by a podiatrist if medically necessary

•	 therapeutic shoes and inserts if medically necessary 

•	 a dilated eye exam and glaucoma screening

•	 flu and pneumonia shots 

•	 diabetes medications 

•	 insulin pumps

•	 kidney function tests

Appendix 4: Medicare for People with 

Diabetes

What Benefits Does Medicare Offer for 

People At Risk for Diabetes?

People enrolled in Medicare who are at risk for type 2 

diabetes may be covered for all or part of the cost of

•	 a “Welcome to Medicare” physical exam when they 

enroll

•	 yearly diabetes screening for people who are at risk for 

diabetes and twice yearly screening for people diagnosed with pre-diabetes (people are considered at risk 

if they have any of the following: high blood pressure, 

history of abnormal cholesterol and triglyceride levels, 

obesity, or a history of high blood glucose) 

•	 cholesterol screening—every five years

To learn more

1-800-MEDICARE (1-800-633-4227), in English and 

Spanish 

TTY/TDD 1-877-486-2048

Medicare and You

http://www.medicare.gov/Publications/Pubs/pdf/10050.pdf

Medicare Coverage of Diabetes Supplies and Services 

http://www.medicare.gov/Publications/Pubs/pdf/11022.pdf

Medicare Information for Caregivers 

http://www.medicare.gov/caregivers/
37 Redesigning the Health Care Team

National Diabetes Education Program

www.YourDiabetesInfo.org

•	 Diabetes HealthSense

•	 Diabetes Numbers At-a-Glance card

•	 Diabetes at Work

•	 Feet Can Last a Lifetime: A Health Care 

Provider’s Guide to Preventing Foot Problems

•	 Guiding Principles for Diabetes Care

•	 Systems Change for Better Diabetes Care 

Models, links, and tools to help health care 

professionals implement systems change 

•	 Transitions—From Pediatric to Adult Health 

Care

•	 Working Together to Manage Diabetes: A Guide 

for Pharmacists, Podiatrists, Optometrists, and 

Dental Professionals, 2007

American Academy of Family Physicians

www.aafp.org

•	 Patient-Centered Medical Home

•	 CD-9 Coding Tools from Family Practice 

Medicine

American Academy of Pediatrics

www.aap.org

•	 Patient-Centered Medical Home

American Association of Clinical 

Endocrinologists

www.aace.com 

•	 AACE Online Endocrine Coding Manual

Team Care-Related Resources

American Association of Diabetes 

Educators

www.diabeteseducator.org

•	 AADE 7

•	 Online learning modules about Medicare DSMT 

and MNT payment provided in a variety of 

practice settings 

•	 Ask the Reimbursement Expert (a free benefit 

for AADE members–login required)

•	 Education program accreditation

•	 Reimbursement Tips for Primary Care Practice, 

revised 2009

•	 Position Statement: Community Health Workers 

in Diabetes Management and Prevention

•	 Guidelines for the Practice of Diabetes 

Education

•	 Competencies for Diabetes Educators 

American College of Physicians

www.acponline.org

•	 ACP Diabetes Care Guide: A Team-Based 

Practice Manual and Self-assessment Program

•	 Patient-Centered Medical Home

American Diabetes Association

www.diabetes.org

•	 Standards of Medical Care in Diabetes – 2010 

(updated yearly)

•	 National Standards for Diabetes SelfManagement Education[31] 

•	 The ADA Education Recognition Program 

Application 
Redesigning the Health Care Team 38 

American Dietetic Association

www.eatright.org

•	 Diabetes MNT reimbursement resources and 

information

•	 The Diabetes Care and Education (DCE) 

Practice Group professional resources

•	 DCE free, reproducible patient education 

materials

American Optometric Association

www.aoa.org

•	 American Optometric Association: Role of 

Retinal Imaging and Comprehensive Eye 

Examinations in the Care of Patients with 

Diabetes, June 2008 

•	 Diabetic Eye Examination Report Form

American Pharmacists Association

www.pharmacist.com

•	 American Pharmacists Association Foundation

•	 Asheville Project

•	 Diabetes Ten City Challenge

American Telemedicine Association

www.americantelemed.org

•	 The American Telemedicine Association 

Telehealth Practice Recommendations 

for Diabetic Retinopathy: A Roadmap of 

Technical Standards, Clinical Guidelines, and 

Administrative Procedures, 2004 

Centers for Disease Control and 

Prevention

www.cdc.org

•	 Community Health Workers/Promotores de 

Salud: Critical Connections in Communities 

Centers for Medicare and Medicaid 

Services (CMS)

www.cms.gov 

•	 Requirements for reimbursement of diabetes 

self-management training

•	 CMS rules for MNT reimbursement 

•	 Medicare coverage for people for people with or 

at risk for diabetes 

•	 Quick Reference Information: Medicare 

Preventive Services

Indian Health Service

www.ihs.gov

•	 The Indian Health Service (IHS)-Joslin Vision 

Network Teleophthalmology Program 

International Diabetes Federation

www.idf.org

•	 Diabetes Education Modules

Peer Support

www.peersforprogress.org

•	 World Health Organization (2007). Peer Support 

Programs in Diabetes 

•	 Peers for Progress 

•	 California Healthcare Foundation, Building Peer 

Support Programs: Seven Models for Success 

Veterans Affairs

www.va.gov 

•	 Diabetes Program

•	 National Veterans Rural Health Resource Center

•	 VHA Directive 2006-050: Preservation—

Amputation Care and Treatment (PACT)
39 Redesigning the Health Care Team

1. Centers for Disease Control and Prevention: 

National diabetes fact sheet: general information 

and national estimates on diabetes in the United 

States, 2011. Atlanta, GA: U.S. Department of 

Health and Human Services, Centers for Disease 

Control and Prevention, 2011.

2. Fagot-Campagna A, Pettitt DJ, Engelgau MM, et 

al.: Type 2 diabetes among North American children and adolescents: an epidemiologic review and 

a public health perspective. J Pediatr 2000; 136(5): 

664-72.

3. Nathan DM, Cleary PA, Backlund JY, et al.: 

Intensive diabetes treatment and cardiovascular 

disease in patients with type 1 diabetes. N Engl J 

Med 2005; 353(25): 2643-53.

4. Holman RR, Paul SK, Bethel MA, et al.: 10-year 

follow-up of intensive glucose control in type 2 

diabetes. N Engl J Med 2008; 359(15): 1577-89.

5. American Diabetes Association: Economic costs of 

diabetes in the U.S. in 2007. Diabetes Care 2008; 

31(3): 596-615.

6. Herman WH, Eastman RC: The effects of treatment 

on the direct costs of diabetes. Diabetes Care 1998; 

21 Suppl 3: C19-24.

7. Gilmer TP, O’Connor PJ, Manning WG, et al.: 

The cost to health plans of poor glycemic control. 

Diabetes Care 1997; 20(12): 1847-53.

8. Knowler WC, Barrett-Connor E, Fowler SE, et al.: 

Reduction in the incidence of type 2 diabetes with 

lifestyle intervention or metformin. N Engl J Med 

2002; 346(6): 393-403.

9. Herman WH, Hoerger TJ, Brandle M, et al.: The 

cost-effectiveness of lifestyle modification or 

metformin in preventing type 2 diabetes in adults 

with impaired glucose tolerance. Ann Intern Med 

2005; 142(5): 323-32.

10. Knowler WC, Fowler SE, Hamman RF, et al.: 

10-year follow-up of diabetes incidence and weight 

loss in the Diabetes Prevention Program Outcomes 

Study. Lancet 2009; 374(9702): 1677-86.

11. Wagner EH: Chronic disease management: What 

will it take to improve care for chronic illness? 

Effective Clinical Practice 1998; 1: 2-4.

12. Bodenheimer T, Wagner EH, Grumbach K: 

Improving primary care for patients with chronic 

illness. JAMA 2002; 288(14): 1775-9.

13. Carrier E, Gourevitch MN, Shah NR: Medical 

homes: challenges in translating theory into practice. Med Care 2009; 47(7): 714-22.

14. Erickson CD, Splett PL, Mullett SS, et al.: The 

healthy learner model for student chronic condition management—part I. J Sch Nurs 2006; 22(6): 

310-8.

15. Peterson KA, Radosevich DM, O’Connor PJ, et 

al.: Improving Diabetes Care in Practice: findings 

from the TRANSLATE trial. Diabetes Care 2008; 

31(12): 2238-43.

16. American Academy of Physician Assistants: 

2008 AAPA Physician Assistant Census Report. 

Alexandria, VA, 2009.

17. Cooper RA: New directions for nurse practitioners 

and physician assistants in the era of physician 

shortages. Acad Med 2007; 82(9): 827-8.

18. Goolsby MJ: 2004 AANP National Nurse 

Practitioner Sample Survey, part I: an overview. J 

Am Acad Nurse Pract 2005; 17(9): 337-41.

19. Roman SH, Harris MI: Management of diabetes mellitus from a public health perspective. 

Endocrinol Metab Clin North Am 1997; 26(3): 

443-74.

20. Bodenheimer T, Wagner EH, Grumbach K: 

Improving primary care for patients with chronic 

illness: the chronic care model, Part 2. JAMA 2002; 

288(15): 1909-14.

21. Tsai AC, Morton SC, Mangione CM, et al.: A 

meta-analysis of interventions to improve care for 

chronic illnesses. Am J Manag Care 2005; 11(8): 

478-88.

References
Redesigning the Health Care Team 40 

22. Robert Graham Center: The Patient Centered 

Medical Home History, Seven Core Features, 

Evidence and Transformational Change. 

Washington, DC: Policy Studies in Family 

Medicine and Primary Care, 2007.

23. Reid RJ, Coleman K, Johnson EA, et al.: The group 

health medical home at year two: cost savings, 

higher patient satisfaction, and less burnout for 

providers. Health Aff (Millwood); 29(5): 835-43.

24. Multi-payer Advanced Primary Care Practice 

(MAPCP) Demonstration Fact Sheet. www.cms.

gov/DemoProjectsEvalRpts/downloads/mapcdemo_

Factsheet.pdf

25. O’Connor PJ, Sperl-Hillen JM: The role of diabetes 

educators in the medical home. Diabetes Spectrum 

2009; 22(2): 124-6.

26. Erickson CD, Splett PL, Mullett SS, et al.: The 

healthy learner model for student chronic condition 

management—part II: the asthma initiative. J Sch 

Nurs 2006; 22(6): 319-29.

27. Quickel KE, Jr.: Managed care and diabetes, with 

special attention to the issue of who should provide 

care. Trans Am Clin Climatol Assoc 1996; 108: 

184-95.

28. Scanlon DP, Hollenbeak CS, Beich J, et al.: 

Financial and clinical impact of team-based treatment for Medicaid enrollees with diabetes in a 

federally qualified health center. Diabetes Care 

2008; 31(11): 2160-5.

29. Huang ES, Zhang Q, Brown SE, et al.: The costeffectiveness of improving diabetes care in U.S. 

federally qualified community health centers. 

Health Serv Res 2007; 42(6 Pt 1): 2174-93; discussion 2294-323.

30. Ray MD: Shared borders: achieving the goals of 

interdisciplinary patient care. Am J Health Syst 

Pharm 1998; 55(13): 1369-74.

31. Funnell MM, Brown TL, Childs BP, et al.: National 

standards for diabetes self-management education. 

Diabetes Care 2007; 30(6): 1630-7.

32. Shojania KG, Ranji SR, McDonald KM, et al.: 

Effects of quality improvement strategies for type 

2 diabetes on glycemic control: a meta-regression 

analysis. JAMA 2006; 296(4): 427-40.

33. Davidson MB, Castellanos M, Duran P, et al.: 

Effective diabetes care by a registered nurse following treatment algorithms in a minority population. 

Am J Manag Care 2006; 12(4): 226-32.

34. Silverstein JH, Rosenbloom AL: Treatment of type 

2 diabetes mellitus in children and adolescents. J 

Pediatr Endocrinol Metab 2000; 13(Suppl 6): 

1403-9.

35. Brink SJ, Miller M, Moltz KC: Education and 

multidisciplinary team care concepts for pediatric and adolescent diabetes mellitus. J Pediatr 

Endocrinol Metab 2002; 15(8): 1113-30.

36. Gaede P, Vedel P, Larsen N, et al.: Multifactorial 

intervention and cardiovascular disease in patients 

with type 2 diabetes. N Engl J Med 2003; 348(5): 

383-93.

37. Gaede P, Lund-Andersen H, Parving HH, et al.: 

Effect of a multifactorial intervention on mortality 

in type 2 diabetes. N Engl J Med 2008; 358(6): 

580-91.

38. Hastings C: The changing multidisciplinary team. 

Nurs Econ 1997; 15(2): 106-8, 105.

39. Engelgau MM, Geiss LS, Manninen DL, et al.: Use 

of services by diabetes patients in managed care 

organizations. Development of a diabetes surveillance system. CDC Diabetes in Managed Care 

Work Group. Diabetes Care 1998; 21(12): 2062-8.

40. American Diabetes Association: Standards of medical care in diabetes—2011. Diabetes Care 2011; 

34(Suppl 1): S11-61.

41. Sarkar U, Handley MA, Gupta R, et al.: Use of 

an interactive, telephone-based self-management 

support program to identify adverse events among 

ambulatory diabetes patients. J Gen Intern Med 

2008; 23(4): 459-65.

42. Fursse J, Clarke M, Jones R, et al.: Early experience in using telemonitoring for the management of 

chronic disease in primary care. J Telemed Telecare 

2008; 14(3): 122-4.

43. Piette JD, McPhee SJ, Weinberger M, et al.: Use of 

automated telephone disease management calls in 

an ethnically diverse sample of low-income patients 

with diabetes. Diabetes Care 1999; 22(8): 1302-9.

44. Adkins JW, Storch EA, Lewin AB, et al.: Homebased behavioral health intervention: Use of a telehealth model to address poor adherence to type-1 

diabetes medical regimens. Telemed J E Health 

2006; 12(3): 370-2.

45. Ferris FL, 3rd: Photocoagulation for diabetic 

retinopathy. Early Treatment Diabetic Retinopathy 

Study Research Group. JAMA 1991; 266(9): 

1263-5.
41 Redesigning the Health Care Team

46. Robinson C: Telemedicine: An emerging technology. One the Cutting Edge; Diabetes Care & 

Education; American Dietetic Association 2007; 

27(6).

47. Scott JC, Conner DA, Venohr I, et al.: Effectiveness 

of a group outpatient visit model for chronically ill 

older health maintenance organization members: a 

2-year randomized trial of the cooperative health 

care clinic. J Am Geriatr Soc 2004; 52(9): 1463-70.

48. Kirsh S, Watts S, Pascuzzi K, et al.: Shared medical 

appointments based on the chronic care model: a 

quality improvement project to address the challenges of patients with diabetes with high cardiovascular risk. Qual Saf Health Care 2007; 16(5): 

349-53.

49. Wagner EH, Grothaus LC, Sandhu N, et al.: 

Chronic care clinics for diabetes in primary care: a 

system-wide randomized trial. Diabetes Care 2001; 

24(4): 695-700.

50. Trento M, Passera P, Borgo E, et al.: A 5-year 

randomized controlled study of learning, problem 

solving ability, and quality of life modifications in 

people with type 2 diabetes managed by group care. 

Diabetes Care 2004; 27(3): 670-5.

51. Clancy DE, Cope DW, Magruder KM, et al.: 

Evaluating group visits in an uninsured or inadequately insured patient population with uncontrolled type 2 diabetes. Diabetes Educ 2003; 29(2): 

292-302.

52. Deakin T, McShane CE, Cade JE, et al.: Group 

based training for self-management strategies in 

people with type 2 diabetes mellitus. Cochrane 

Database Syst Rev 2005(2): CD003417.

53. Davies MJ, Heller S, Skinner TC, et al.: 

Effectiveness of the diabetes education and self 

management for ongoing and newly diagnosed 

(DESMOND) programme for people with newly 

diagnosed type 2 diabetes: cluster randomised 

controlled trial. BMJ 2008; 336(7642): 491-5.

54. Gage H, Hampson S, Skinner TC, et al.: 

Educational and psychosocial programmes for 

adolescents with diabetes: approaches, outcomes 

and cost-effectiveness. Patient Educ Couns 2004; 

53(3): 333-46.

55. Hampson SE, Skinner TC, Hart J, et al.: Effects 

of educational and psychosocial interventions for 

adolescents with diabetes mellitus: a systematic 

review. Health Technol Assess 2001; 5(10): 1-79.

56. Klonoff DC, Schwartz DM: An economic analysis 

of interventions for diabetes. Diabetes Care 2000; 

23(3): 390-404.

57. Loveman E, Cave C, Green C, et al.: The clinical 

and cost-effectiveness of patient education models 

for diabetes: a systematic review and economic 

evaluation. Health Technol Assess 2003; 7(22): iii, 

1-190.

58. Norris SL, Nichols PJ, Caspersen CJ, et al.: 

Increasing diabetes self-management education in 

community settings. A systematic review. Am J 

Prev Med 2002; 22(4 Suppl): 39-66.

59. Boren SA, Fitzner KA, Panhalkar PS, et al.: Costs 

and benefits associated with diabetes education: a 

review of the literature. Diabetes Educ 2009; 35(1): 

72-96.

60. Robbins JM, Thatcher GE, Webb DA, et al.: 

Nutritionist visits, diabetes classes, and hospitalization rates and charges: the Urban Diabetes Study. 

Diabetes Care 2008; 31(4): 655-60.

61. Duncan I, Birkmeyer C, Coughlin S, et al.: 

Assessing the value of diabetes education. Diabetes 

Educ 2009; 35(5): 752-60.

62. Kilpatrick KE, Brownson CA: Building the business case for diabetes self management: a handbook for program managers. St. Louis: Diabetes 

Initiative, National Program Office at Washington 

University School of Medicine, 2008.

63. Brownson CA, O’Toole ML, Gowri S, et al.: 

Clinic-community partnerships: A foundation for 

providing community supports for diabetes care and 

self-management. Diabetes Spectrum 2007; 20(4): 

209-214.

64. Finch EA, Kelly MS, Marrero DG, et al.: Training 

YMCA wellness instructors to deliver an adapted 

version of the Diabetes Prevention Program lifestyle 

intervention. Diabetes Educ 2009; 35(2): 224-8, 

232.

65. Ackermann RT, Finch EA, Brizendine E, et al.: 

Translating the Diabetes Prevention Program into 

the community. The DEPLOY Pilot Study. Am J 

Prev Med 2008; 35(4): 357-63.

66. Janicke DM, Sallinen BJ, Perri MG, et al.: 

Comparison of parent-only vs family-based interventions for overweight children in underserved 

rural settings: outcomes from project STORY. Arch 

Pediatr Adolesc Med 2008; 162(12): 1119-25.
Redesigning the Health Care Team 42 

67. Janicke DM, Sallinen BJ, Perri MG, et al.: 

Comparison of program costs for parent-only and 

family-based interventions for pediatric obesity in 

medically underserved rural settings. J Rural Health 

2009; 25(3): 326-30.

68. Norris SL, Chowdhury FM, Van Le K, et al.: 

Effectiveness of community health workers in the 

care of persons with diabetes. Diabet Med 2006; 

23(5): 544-56.

69. Heisler M: Building peer suport programs: Seven 

models for success. Oakland, CA: California 

Healthcare Foundation, 2006.

70. Domurat ES: Diabetes managed care and clinical outcomes: the Harbor City, California Kaiser 

Permanente diabetes care system. Am J Manag 

Care 1999; 5(10): 1299-307.

71. Caravalho JY, Saylor CR: An evaluation of a nurse 

case-managed program for children with diabetes. 

Pediatr Nurs 2000; 26(3): 296-300, 328.

72. Marshall CL, Bluestein M, Briere E, et al.: 

Improving outpatient diabetes management 

through a collaboration of six competing, capitated 

Medicare managed care plans. Am J Med Qual 

2000; 15(2): 65-71.

73. Driver VR, Madsen J, Goodman RA: Reducing 

amputation rates in patients with diabetes at a military medical center: the limb preservation service 

model. Diabetes Care 2005; 28(2): 248-53.

74. Rith-Najarian S, Dannels E, Acton K: Preventing 

amputations from diabetes mellitus: the Indian 

Health Service experience. West Indian Med J 

2001; 50 Suppl 1: 41-3.

75. Frykberg RG: Diabetic foot ulcerations: management and adjunctive therapy. Clin Podiatr Med Surg 

2003; 20(4): 709-28.

76. Wrobel JS, Charns MP, Diehr P, et al.: The 

relationship between provider coordination and 

diabetes-related foot outcomes. Diabetes Care 2003; 

26(11): 3042-7.

77. Haase R, Russell S: Improving diabetes care and 

outcomes in a rural primary care clinic. Jt Comm J 

Qual Patient Saf 2006; 32(5): 246-52.

78. Siminerio LM, Piatt G, Zgibor JC: Implementing 

the chronic care model for improvements in 

diabetes care and education in a rural primary care 

practice. Diabetes Educ 2005; 31(2): 225-34.

79. Litaker D, Mion L, Planavsky L, et al.: Physician - 

nurse practitioner teams in chronic disease management: the impact on costs, clinical effectiveness, 

and patients’ perception of care. J Interprof Care 

2003; 17(3): 223-37.

80. Solberg LI, Klevan DH, Asche SE: Crossing the 

quality chasm for diabetes care: the power of one 

physician, his team, and systems thinking. J Am 

Board Fam Med 2007; 20(3): 299-306.

81. Ginsberg BH, Tan MH, Mazze R, et al.: Staged 

diabetes management: computerizing a disease state 

management program. J Med Syst 1998; 22(2): 

77-87.

82. Hirsch IB, Goldberg HI, Ellsworth A, et al.: A 

multifaceted intervention in support of diabetes 

treatment guidelines: a cont trial. Diabetes Res Clin 

Pract 2002; 58(1): 27-36.

83. International Diabetes Federation Clinical 

GuidelinesTask Force: IDF Guideline on oral health 

for people with diabetes. Brussels, 2009.

84. Albert DA, Sadowsky D, Papapanou P, et al.: An 

examination opopulation. BMC Health Serv Res 

2006; 6: 103.

85. Eke PI, Genco RJ: CDC Periodontal Disease 

Surveillance Project: background, objectives, and 

progress report. J Periodontol 2007; 78(7 Suppl): 

1366-71.

86. World Health Organization: Report on the Global 

Tobacco Epidemic: the MPOWER package. 

Geneva, 2008.

87. Katon W, Unutzer J, Fan MY, et al.: Costeffectiveness and net benefit of enhanced treatment 

of depression for older adults with diabetes and 

depression. Diabetes Care 2006; 29(2): 265-70.

88. Hunkeler EM, Katon W, Tang L, et al.: Long term 

outcomes from the IMPACT randomised trial for 

depressed elderly patients in primary care. BMJ 

2006; 332(7536): 259-63.

89. Mukhtar Q, Jack L, Jr., Martin M, et al.: Evaluating 

progress toward Healthy People 2010 national 

diabetes objectives. Prev Chronic Dis 2006; 3(1): 

A11.

90. Aiello LP, Cahill MT, Wong JS: Systemic considerations in the management of diabetic retinopathy. 

Am J Ophthalmol 2001; 132(5): 760-76.
43 Redesigning the Health Care Team

91. Winters JE, Messner LV, Gable EM, et al.: 

Coordinating eye and primary medical care in 

a low-income and uninsured population: the 

experience of the Vision of Hope Health Alliance. 

Optometry 2008; 79(12): 730-6.

92. Persaud DD, Jreige S, LeBlanc RP: Enhancing 

vision care integration: 1. Development of practice 

algorithms. Can J Ophthalmol 2004; 39(3): 219-24.

93. Jones SL, Nichols KK: Diabetic eye examination 

report. Optometry 2007; 78(11): 588-95.

94. Siminerio LM, Piatt GA, Emerson S, et al.: 

Deploying the chronic care model to implement 

and sustain diabetes self-management training 

programs. Diabetes Educ 2006; 32(2): 253-60.

95. Wubben DP, Vivian EM: Effects of pharmacist 

outpatient interventions on adults with diabetes 

mellitus: a systematic review. Pharmacotherapy 

2008; 28(4): 421-36.

96. Johnson CL, Nicholas A, Divine H, et al.: 

Outcomes from DiabetesCARE: a pharmacistprovided diabetes management service. J Am 

Pharm Assoc (2003) 2008; 48(6): 722-30.

97. Divine H, Nicholas A, Johnson CL, et al.: 

PharmacistCARE: description of a pharmacist care 

service and lessons learned along the way. J Am 

Pharm Assoc (2003) 2008; 48(6): 793-802.

98. Cranor CW, Bunting BA, Christensen DB: The 

Asheville Project: long-term clinical and economic 

outcomes of a community pharmacy diabetes care 

program. J Am Pharm Assoc (Wash) 2003; 43(2): 

173-84.

99. Fera T, Bluml BM, Ellis WM: Diabetes Ten City 

Challenge: final economic and clinical results. J Am 

Pharm Assoc (2003) 2009; 49(3): 383-91.

100. Lavery LA, Wunderlich RP, Tredwell JL: Disease 

management for the diabetic foot: effectiveness of a 

diabetic foot prevention program to reduce amputations and hospitalizations. Diabetes Res Clin Pract 

2005; 70(1): 31-7.

101. Fitzgerald RH, Mills JL, Joseph W, et al.: The 

diabetic rapid response acute foot team: 7 essential 

skills for targeted limb salvage. Eplasty 2009; 9: 

e15.

102. Sumpio BE, Armstrong DG, Lavery LA, et al.: 

The role of interdisciplinary team approach in the 

management of the diabetic foot: a joint statement 

from the Society for Vascular Surgery and the 

American Podiatric Medical Association. J Vasc 

Surg 2010; 51(6): 1504-6.

103. Attinger CE, Hoang H, Steinberg J, et al.: How to 

make a hospital-based wound center financially 

viable: the Georgetown University Hospital model. 

Gynecol Oncol 2008; 111(2 Suppl): S92-7.

104. Wolf AM, Conaway MR, Crowther JQ, et al.: 

Translating lifestyle intervention to practice in 

obese patients with type 2 diabetes: Improving 

Control with Activity and Nutrition (ICAN) study. 

Diabetes Care 2004; 27(7): 1570-6.

105. Wolf AM, Siadaty M, Yaeger B, et al.: Effects 

of lifestyle intervention on health care costs: 

Improving Control with Activity and Nutrition 

(ICAN). J Am Diet Assoc 2007; 107(8): 1365-73.

106. Hiss RG, Armbruster BA, Gillard ML, et al.: Nurse 

care manager collaboration with community-based 

physicians providing diabetes care: a randomized controlled trial. Diabetes Educ 2007; 33(3): 

493-502.

107. Polonsky WH, Earles J, Smith S, et al.: Integrating 

medical management with diabetes self-management training: a randomized control trial of the 

Diabetes Outpatient Intensive Treatment program. 

Diabetes Care 2003; 26(11): 3048-53.

108. Newton KM, Wagner EH, Ramsey SD, et al.: The 

use of automated data to identify complications and 

comorbidities of diabetes: a validation study. J Clin 

Epidemiol 1999; 52(3): 199-207.

109. Selby JV, Karter AJ, Ackerson LM, et al.: 

Developing a prediction rule from automate clinical 

databases to identify high-risk patients in a large 

population with diabetes. Diabetes Care 2001; 

24(9): 1547-55.
Redesigning the Health Care Team 44 
Redesigning the Health Care Team

Suggested Citation: 

National Diabetes Education Program, National Institutes of Health. Redesigning the Health Care Team: Diabetes 

Prevention and Lifelong Management. Bethesda, Maryland: U.S. Department of Health and Human Services, 2011. 
The U.S. Department of Health and Human Services’ National Diabetes Education Program is 

jointly sponsored by the National Institutes of Heath and the Centers for Disease Control and Prevention 

with the support of more than 200 partner organizations.

Participants in clinical trials can play a more active role in their own health care, gain access to new research treatments 

before they are widely available, and help others by contributing to medical research. 

For information about current studies, visit www.ClinicalTrials.gov.

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NIH Publication No. 11-7739 NDEP-37 Revised June 2011