Then, Dr. Elliott P. Joslin practiced from his home on Bay State Road in Boston with his teaching nurse. This "wandering" nurse would go to patients' homes to teach many aspects of diabetes management, including monitoring of urine and food preparation.

Joslin's clinic has changed and expanded since then, as has the scope of the diabetes team, which today includes nurses, dietitians, mental health providers, exercise physiologists, ophthalmologists, nephrologists, podiatrists, nurse practitioners, and endocrinologists. What remains unchanged is the need for a coordinated approach to care and education involving a team of professionals.

The demand for comprehensive diabetes care is on the rise and has increased at our clinic by 25% since last year alone. We are now in the process of redesigning our team approach to improve efficiency in light of the increased demand. The following case illustrates the new process and the some of the benefits of the team approach.

During the phone conversation, the educator learned that D.R. is a 21-year-old caucasian woman newly diagnosed with diabetes. Two days before her call, she was noted to have a random blood glucose of 245 mg/dl as part of an evaluation for an upper respiratory infection at an urgent care center. In retrospect, she reported polyuria and polydipsia for approximately 1 year preceding the urgent care visit. She also reported a recent 15-lb weight loss.

D.R. was quite anxious about her new diagnosis. She had been given a prescription for glipizide at the urgent care center, but had not filled it. She did not have a primary care physician.

The educator felt that this case required an urgent evaluation because the type of diabetes was in question, the diabetes was untreated, and the patient had not been taught home blood glucose monitoring.

Appointments were made for D.R. to see the endocrinologist and nurse educator 2 days later. A dietitian appointment was also made at the first available time, which was 6 days after the initial call.

She also emphasized the importance of home blood glucose monitoring in diabetes management and instructed D.R. on proper use of a blood glucose meter. She reviewed premeal and 2-h postprandial target blood glucose ranges, and she discussed record-keeping and reviewed the use of a blood glucose log sheet.

She also reinforced the diabetes care triad and explained how nutrition, exercise, and medication can affect blood glucose readings. She emphasized the need for a return visit with the nurse educator and dietitian for diabetes management.

Her medical history was significant for rapid growth as a child, irregular periods since menarche at age 11, and longstanding hirsutism. A trial of oral contraceptive pills (OCPs) had regulated her periods in the past but had no significant effect on her hirsutism, which had become more prominent in the past 4 years. An evaluation for this at her pediatrician's office had been unrevealing.

D.R. was a junior in college. She did not exercise. The physician briefly reviewed her diet history and noted the need for dietary changes. She had no allergies and was on no medications.

Her family history was remarkable for coronary artery disease, type 2 diabetes, and hypertension in grandparents. There was no family history of hirsutism, infertility, or polycystic ovarian syndrome (POS).

On physical exam, she weighed 231 lb and was 5 feet 9 inches. Her blood pressure was 120/80 mmHg. Acne, masculine body build, and excess facial, chest, and back hair were noted. Two small micro-aneurysms were noted on fundoscopic exam. D.R.'s thyroid, heart, lung, and abdominal exams were otherwise normal. Her clitoris was not enlarged. Her feet were in good repair, with normal pulses and sensation.

Given the longstanding history of hirsutism and irregular menses, the physician felt that a virilizing tumor was unlikely and that the diagnosis was either POS or possibly congenital adrenal hyperplasia. The plan was to obtain her pediatrician's records and perform a cosyntropin stimulation test to rule out congenital adrenal hyperplasia. The physician reviewed with D.R. the possible diagnoses and their implications.

The physician also discussed prevention of diabetes complications and gave a thorough explanation of diabetes, POS, and pregnancy.

D.R. and the physician defined goals for an HbA_1c of <6.5% and a fasting blood glucose <120 mg/dl. The physician recommended metformin, 500 mg daily, instead of glipizide and planned to increase the metformin dosage as tolerated.

The physician stressed the importance of regular aerobic exercise and, pending her appointment with the dietitian, advised D.R. to switch from regular to diet colas, substitute non-sugar cereals for pop tarts at breakfast, and avoid late-night sweets.

The dietitian reviewed her home blood glucose data. Her records indicated:

The dietitian also noted D.R.'s cholesterol profile (Table 1). D.R. lives at home and shares the responsibilities of shopping and cooking with her mother. She dines out frequently with friends, usually at fast-food restaurants. She also frequently has brownies as an evening snack. She avoids milk products because of lactose intolerance. However, she had eliminated regular sodas and changed her breakfast habits since meeting with the physician.

The dietitian developed an 1,800- to 2,200-kcal meal plan focusing on decreasing the saturated fat in D.R.'s diet (because of her lipid status) and controlling the portions of her carbohydrates. D.R. was accustomed to eating snacks, so she and the dietitian planned her carbohydrate distribution as follows:

The dietitian recommended that D.R. keep food records along with blood glucose records to assist in determining whether further changes were needed.

The results of the cosyntropin stimulation test and other endocrine testing are shown in Table 2. A 24-h urine for cortisol was normal. These data were interpreted as being consistent with POS, and this diagnosis was further discussed. Metformin was further increased to 1,000 mg twice daily.

Utilizing a triage system (Figure 1) allowed the clinic to schedule timely appointments for this patient not only with a physician but also with other appropriate members of the health care team. The goal of improving access to care via this system is to allow all patients to be seen within 48 h by the most appropriate providers. In this case, which involved a newly diagnosed patient, evaluations by the physician, nurse educator, and dietitian were all necessary and were scheduled at the time of the initial call.

At the Joslin Center, new patients receive an educational needs assessment immediately before the physician's initial evaluation. Patient education is a cornerstone of diabetes treatment. Figure 2 shows our center's education record. Structuring the educational needs assessment in this way allows for more focused educational interventions and gives physicians more time with patients.

Figure 2. Joslin Clinic's diabetes self-management education record

As in every case of diabetes, the physician's assessment is vital. The physician clarifies the underlying physiology and, together with the patient, determines the specific recommendations for meal plan, exercise, and medical therapy.

The implementation of the team model is meant to improve access for both new and returning patients, increase productivity, and optimize patient care. Communication among health care providers is essential if the team model is to be successful.

Communication via regular team meetings and frequent contact between disciplines promoted effective care for this patient. Weight loss, improvement in signs and symptoms of POS, and achievement of diabetes management goals were accomplished. Long-term follow-up with team members is essential to support D.R.'s lifestyle changes and address her needs as they arise.