Team-Based Approaches to Wellness takes into consideration the Chronic Care Model (CCM), which is composed of six elements that optimize the care for patients with chronic diseases such as diabetes. These elements include delivery system design, self-management support, decision support, clinical information systems for patients to access their own information, connecting individuals with community resources and policies, and health systems. Team-Based Approaches to Wellness also focuses on implementing strategies for System-Level Improvements where care teams should prioritize the intensification of lifestyle and pharmacologic therapy, specifically for patients with diabetes that have not achieved metabolic targets. Strategies for care team intensification include setting collaborative goals with patients, addressing and identifying barriers related to language, numeracy, and cultural barriers to care, integrating evidence-based guidelines and clinical information into the process of care, providing structures, obtaining feedback from patients, setting reminders that will help meet targets and incorporating care management teams.
For more information on this promising practice, go to Building an Effective Collaborative Care Team to Address Diabetes in Special and Vulnerable Populations: Tailoring Care for Social Context
Resource: Analytic Framework: Team-Based Care for Diabetes Management