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Integrated Approaches to the Management of NIDDM Patients
Martha Mitchell Funnell, MS, RN, CDE

Since the 1970s, diabetes has been viewed as the prototypical disease model for a team approach to care because of the complexity of its management, the variety of health-care disciplines involved, and the critical need for self-management and daily decision-making by the people who have it.^1,2 Health-care professional team members typically include at least a physician, nurse, and dietitian with other members (e.g., endocrinologist, diabetologist, internist, primary care or family practitioner, certified diabetes educator (CDE), behavioral specialist, social worker, psychologist, psychiatrist, pharmacist, exercise physiologist, ophthalmologist, nephrologist, podiatrist) included as needed.

The announcement of the results of the Diabetes Control andCompli- cations Trial (DCCT),³ and resulting interest in more intensive regimens has led to reexamination and revitalization of the team concept and definition of team members’ roles. There is also a need to translate the DCCT findings to people with non-insulin-dependent diabetes mellitus (NIDDM)^4-7 and to find ways to improve their care. The purpose of this article is to define models of team care, identify strategies to optimize management among people with NIDDM, and describe integrated care for optimal management of NIDDM, including requirements for integrated care, team activities, delivery models, and health professional training.

Models of Team Care
In the workplace, a team is defined as a group of people who, by design, work together to achieve a common outcome.⁸ Types of teams are differentiated by their identity, manner of work, and leadership. There are two distinct types of health-care teams: multidisciplinary and interdisciplinary. Although the terms multidisciplinary and interdisciplinary are often used interchangeably, there are key differences as outlined in Table 1.

The traditional view of diabetes care teams is multidisciplinary. In this model, each health professional represents his or her particular discipline, retains his or her professional identity, works interdependently, and consults with the other team members.1 Leadership is clearly defined and efforts are divided according to specialty. This approach was developed in the context of the acute-care medical model of health-care delivery and is generally compatible with inpatient care of diabetes. Hospital staffing patterns are typically divided by departments that function autonomously, official lines of communication are hierarchical, and collaboration is often through written communication, such as chart notes.⁴

With the advent of prospective payment, most chronic illness care has moved to the outpatient arena. The concept and implementation of multidisciplinary team care is extremely difficult in this environment, for several reasons. First, it is time-consuming for patients to meet with several professionals, and time with nonphysician providers may not be reimbursed by insurance payors. Second, teams that work outside of the inpatient environment require greater teamwork and communication than those that work in the same space and under the same controls.⁹ Communication difficulties are exacerbated as professionals work in different locations or on different days. As a result, care recommendations may become fragmented and unclear, resulting in frustrated patients and providers.

While use of a team conference would greatly enhance coordination, it is often impractical for team members to meet consistently to present their findings and reach consensus about treatment recommendations. In addition, patients generally are not part of these teams, and because each professional interprets patients’ viewpoints, their goals may not be accurately represented.

In an effort to deal with these constraints and still provide optimal care, many diabetes care teams have developed an interdisciplinary approach. Interdisciplinary teams have a shared identity, shared goals, and shared leadership.¹ A group of health professionals becomes an interdisciplinary team when they examine their skills, negotiate roles and functions of each team member, and collaborate to resolve questions about these areas of potential conflict.¹⁰ In order to function smoothly, successful interdisciplinary teams need to share a common philosophy and respect the viewpoints and abilities of the other team members.^2,8,11 The efforts of the team members need to become complementary, cohesive, and fluid with shared leadership that is task-dependent.

Optimizing Management of NIDDM
Although the DCCT participants had insulin-dependent diabetes mellitus (IDDM), the results are believed to apply to patients with NIDDM as well. ^5-7,12 Optimal management for NIDDM remains somewhat controversial and less clearly defined. However, because NIDDM generally occurs among people who are older, overweight, and sedentary, optimizing metabolic control often includes a renewed emphasis on medical nutritional therapy, weight loss, and exercise programs.⁵ As a result, optimal therapy for NIDDM requires a team approach to ensure that patients have access to the professionals who can best provide the needed expertise.

The intensity of the regimens needed to achieve target hemoglobin A_1c levels during the DCCT led to renewed interest in diabetes care teams.^3,12-14 The contribution of the team approach to the success of the DCCT is unknown, and it is probably not possible to duplicate the expertise and intensity of DCCT team interactions for NIDDM patients because of the associated costs.¹⁵ However, the DCCT experience suggests that people seeking optimal metabolic control will need team care,⁵ and also provides information about strategies that can facilitate attainment of this goal. While there were differences in the ways each of the various DCCT teams operated, many of these teams redefined roles and functions and eventually became interdisciplinary in nature. For example, nurses and some dietitians made insulin dose recommendations, a task that has traditionally belonged to physicians.^12-14,16

Optimal management of diabetes requires a different approach than multidisciplinary care, in which the physician plays a dominant and directive role, other health professionals play a supportive role to the physician and an intermediary role with patients, and patients play an informed but passive role.⁴ Patients with diabetes provide 95–99% of their own care, and their long-term outcomes are largely determined by the multiple daily decisions that they make in meeting their goals.¹⁷ Since all aspects of the diabetes treatment regimen are lifestyle-related, people with diabetes must assume the greatest responsibility for their ongoing care and outcomes. The choice to initiate and maintain optimal therapy must be made by the patient, who bears both the responsibility for and the consequences of the outcomes achieved.⁴ This is true regardless of how strongly health professionals desire and value metabolic control,¹⁸ or the methods of therapy selected.

It is for these reasons that optimal care for NIDDM must be integrated into a patient-centered approach, in which both the goals and the care result from the collaborative efforts of the patient and the interdisciplinary team, functioning as an expert support system.⁴ In order for this process to work effectively, people with diabetes must understand the potential costs and benefits of the regimen, participate in the development of a regimen that is consistent with their goals and lifestyle, and have the skills, knowledge, and attitudes needed to carry out the treatment program and seek support as needed.²

Integrated Care for Optimizing Management of NIDDM
Using an interdisciplinary approach results in integrated care. Integrated care is structured around product rather than functional lines,4 so that patients receive care, education, and psychosocial support from each member of the interdisciplinary team of professionals. As a result, patients not only receive high quality metabolic care, but also are able to become active, well-informed, self-management experts. By definition, integrated care for diabetes must be patient-centered and goal-directed. Integration of care is believed to be a critical element of providing optimal management for people with NIDDM4 and serves as the basis for developing team care delivery models.

While the value of integrated care for the treatment of IDDM has been demonstrated,3,19 there is also support for an integrated approach in the optimal treatment of NIDDM.20-23 Halter and associates,20 found that adults over 65 years old who participated in an interdisciplinary program of intensified insulin therapy, education, and support experienced significant declines in glycosylated hemoglobin levels, with a low risk for hypoglycemia, and with no significant impact on weight, lipid levels, blood pressure, or quality of life. The introduction of a structured treatment and educational program for non-insulin-treated patients in primary care practices in Germany resulted in decreased use of sulfonylureas and lower glycosylated hemoglobins, weights, and triglycerides.21,22

Requirements for Integrated Care
Metabolic Control Matters⁴ defines integrated care as requiring:
• Emphasis on education, counseling, and medical treatment. Each of these components is equally impor- tant, and no area should be exclud- ed, although different aspects may be emphasized at different times depending on patient needs. Education and counseling need to be provided as an integral part of medical care, not as an adjunct to it.
• Interactive communication among professionals and patients. Patients and professionals must become partners in diabetes care. While pro- fessionals are experts on diabetes, patients are the experts on their own lives and goals. Valid decisions require equal input from both.
• A patient-centered focus. It has been suggested that providing each patient with sufficient information to make an informed choice and then asking that they make a deci- sion about the level of therapy that is consistent with their values and goals, may be the most effective approach to preventing complications.¹⁸

In addition, the use of standard diabetes protocols has also been recommended in supporting integrated care.²³ Standard protocols have the advantage of increasing understanding of, and access and referral to, other team members, enhancing the likelihood that standards of care are met, and facilitating patient involvement and goal-setting. These approaches are consistent with an integrated model that combines all aspects of diabetes care.

Integrated Care Team Activities
Diabetes care is sufficiently complex that no single discipline possesses all of the expertise and skills needed to provide comprehensive treatment. Because the role each member plays varies when carried out within the context of an interdisciplinary model, determining critical activities for the team is more in keeping with an integrated approach than defining roles by discipline. Table ² outlines critical activities for the implementation of optimal therapy. The appropriate team member to lead and carry out these activities is determined collaboratively by each team, based on the knowledge, skills, strengths, and desires of its members and its care delivery environment.

Barriers
While studies of integrated care models support their efficacy, there are barriers to widespread implementation of this approach. For example, current practice patterns of physician-managed diabetes care is a barrier that exists largely because of the reimbursement structure. Education and counseling are generally not reimbursed by third-party payers. In addition, the number of health professionals trained in both optimal management of diabetes and interdisciplinary teams, who can therefore function effectively in an integrated care system, is limited.⁴

Integrated Models
One model of integrated care that has been proposed is the Shared Care Model.⁴ In this two-step process, NIDDM patients first receive an annual evaluation in a diabetes care center, with follow-up care delivered by a primary care physician and integrated team. The annual evaluation includes a review of metabolic parameters; monitoring for complications; and assessment of behavioral, pyschosocial, educational, and nutritional needs and functions; and collaborative goal-setting by the patient and team, who together then set forth the plan for the next year. This allows NIDDM patients access to diabetes experts and helps to ensure that standards of care are met. It emphasizes all of the required elements for integrated care and is more likely to be reimbursed than ongoing care for NIDDM by diabetes care specialists.⁴ Another option for this first step is the development and adoption of standard protocols by diabetes experts and primary care providers that take into account accepted standards of care and facilitate interaction with other health-care disciplines.²³

In addition to the Shared Care Model, there are several other models for ongoing care resulting in optimal diabetes management that meet the requirements for integrated care and could be selected for implementation. The model chosen depends on the therapy chosen and available resources. There is no one right model, and creativity will be needed to overcome existing barriers.

One approach is ongoing management by the primary care physician and patient. This has the advantage of being largely reimbursed, and because of its similarity to our current delivery system, it is widely acceptable. However, it will likely be difficult for one person to provide all of the required elements and activities for integrated care, even with the help of the annual evaluation process or standard protocols. This is particularly true for more intensive therapies and those that are largely based on a dietary and exercise approach to treatment.

Another proposed model is for a primary care physician to form an integrated care team with other local diabetes experts, such as another physician with expertise in diabetes care, an ophthalmologist, a podiatrist, a diabetes educator, a dietitian, or a social worker. This has the advantages of being more compatible with current practice patterns and of increasing access to integrated care on a local level. Reimburse- ment may be available for many of these services, such as podiatry, but may not be available for other services, such as diabetes education or medical nutritional therapy.

Other models of integrated care incorporate the roles of nonphysician team members in providing components of treatment. This increases access by expanding the number of health

professionals with expertise in diabetes. Use of tiered care protocols has been suggested as a method to determine the most appropriate team members to work with a particular patient when implementing optimal therapy.²⁴

Case management or care coordination is one such model. The case manager integrates, coordinates, and advocates for people needing extensive health-care services by optimizing patients’ self-care capabilities and the efficient use of resources, with the goal of achieving planned outcomes through coordination of care.^25,26 Case management is appropriate for optimal diabetes care because it is patient-centered, cost effective, maximizes team interaction, minimizes fragmentation of care, and provides patients with a practitioner who has the in-depth knowledge and skill to coordinate their care.²⁷

This approach is particularly appropriate for patients whose diabetes is largely managed through medical nutritional therapy and exercise. For these patients, ongoing access to a dietitian or nurse educator may provide the in-depth information and support needed, and will more likely result in optimal metabolic control than episodic physician visits. While most case managers are nurses, other certified diabetes educators, such as nutritionists, are also appropriate care coordinators, particularly among NIDDM patients for whom medical nutritional therapy and exercise are the primary interventions. Case managers could be employed by a primary care physician to provide coordination for a variety of chronically ill patients, by a practice, by a managed care provider, or by the diabetes center where the annual evaluation is performed or standards developed.

Another model is that of collaborative practice, where an advanced practice nurse with expertise in diabetes and a physician share responsibility for a group of patients.²⁸ Collaboration implies interdependence, allows for patient-centered care, and may incorporate the use of protocols.²⁹ The efficacy of advanced practice nurses with expertise in diabetes providing care has been demonstrated,^30-32 but this model is limited by lack of reimbursement, prescriptive restrictions, and lack of available advanced practice nurses who are trained in optimal management of diabetes.⁴ An additional concern is that the care shifts from physician-managed to nurse-managed, rather than to integrated care.

Health Professional Training
As mentioned previously, one major barrier to integrated care is the lack of available, trained health professionals. Training is needed by all members of the team in both the optimal management of diabetes and interdisciplinary care.^4,24,33-35 The number of nonphysician providers with diabetes expertise will need to increase substantially if they are to assume a more responsible role in the care of patients. The current number of 8900 CDEs is not adequate to provide care coordination for the estimated ⁸ million people with known diabetes in this country. In addition, current advanced practice programs for nurses provide only limited training in diabetes, resulting in advanced practice nurses who receive primarily on-the-job training in diabetes and therefore may not provide care that meets accepted standards of care.³⁵

Current training of health-care professionals, done largely on an inpatient basis, is generally multidisciplinary care, which promotes autonomy rather than the interdependent functioning needed to provide integrated care.1 Team members must be knowledgeable about the process, recognize values and benefits, and be willing to work in an interdisciplinary setting.³⁶ Therefore, training to function as an interdisciplinary team member must occur for it to operate effectively. Intraprofessional training, defined as training provided by a variety of health professionals, has been shown to increase willingness to share responsibilities³⁷ and to modify specific role expectations³⁸ among physicians, but few such programs have been implemented.

Conclusion
Comprehensive health care necessitates such a broad spectrum of knowledge that no one health-care professional can easily provide the array of services needed.²⁹ This is particularly true for the optimal management of NIDDM, where medical management, education, psychosocial adjustment, and behavioral change must all occur and are of equal importance. Integrated care is an essential component in the treatment of diabetes, and patients, nonphysician health-care professionals, and physicians must become active participants with shared responsibilities in the health-care team. While barriers, particularly lack of reimbursement, exist, we must be creative in designing models for interdisciplinary, integrated care, if optimal care for the large number of patients with NIDDM is to occur.


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Acknowledgments
This paper was supported in part by grant number NIH5P60 DK20572 from the National Institute of Diabetes and Digestive and Kidney Diseases.

The author gratefully acknowledges Amy Bonneau and Kelly Fearer for their secretarial support.



Martha Mitchell Funnell, MS, RN, CDE, is associate director for adminnistration of the Clinical Implementation Core of the Diabetes Research and Training Center at the University of Michigan, in Ann Arbor.

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