Volume 11 Number 1, 1998, Pages 33-37
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The Team Approach to Intensive Diabetes Management
Meg Bayless, BSN, RN, CDE, and Cathy Martin, MS, RN, CDE
The number of people diagnosed with diabetes in the United States is expected to increase, perhaps by 2 million, as a direct result of changes made earlier this year to diabetes screening recommendations and diagnostic criteria.1 These revised methods will allow timely diagnosis of diabetes and give the health care system an unprecedented opportunity to initiate metabolic control before the onset of complications.
This influx of newly diagnosed individuals is in addition to the 8 million people already diagnosed with diabetes. With annual costs related to diabetes exceeding $90 billion,2 providing efficient and effective diabetes care is increasingly important.
In 1993, the results of the landmark Diabetes Control and Complications Trial (DCCT) provided clear evidence that metabolic control matters for people with type 1 diabetes.3,4 This dictum is quickly gaining acceptance for type 2 diabetes, as well.5 But as the debate about glycemic control and complications is put to rest, perhaps a more complex and controversial issue arises: how can intensive therapy be implemented for increasing numbers of people with diabetes?
Broadly defined, intensive diabetes management aims to achieve optimum glycemic control using advanced techniques in insulin therapy, self-monitoring of blood glucose (SMBG), nutrition, and behavioral sciences.6 Intensive management is far more than increased frequency of monitoring or an additional injection of insulin per day. It requires careful follow-up to monitor progress toward individualized goals and support to reinforce management skills and personal efforts.
Such complexities extend beyond the scope of sole practitioners. It is not surprising that intensive diabetes management requires a core group of skilled professionals with diverse roles, functions, and contributions: the interdisciplinary team.
The interdisciplinary, integrated care team as a model for the treatment of chronic illness is not a new concept. Its benefits have been supported in a variety of disorders.7-11 Adoption of this model is relatively new to diabetes, however, and requires a shift in how diabetes providers view their roles and relationships, both with patients and with professionals in other disciplines.
Recognition of the complexity of diabetes treatment has prompted both the American Diabetes Association and the American Association of Diabetes Educators to endorse team management as the ideal model for the delivery of diabetes care.12,13
Composition of the Diabetes Treatment Team
Teams may also extend to health care professionals who can help meet special or specific needs not within the scope of the core teams expertise. For example, podiatrists, exercise physiologists, ophthalmologists, pharmacists, or specialists in maternal-child care or gerontology may have a place within the diabetes care team.
The existence of a diabetes care team implies the development of a comprehensive diabetes care program ensuring that standards of care are met.5 Care should be research-based and outcome-focused. Mutual support of team members will encourage ongoing professional development and support of critical thinking skills.14
Leadership, Roles, and Functions
The movement toward interdisciplinary care requires changes in team organization. In traditional medical models of care, the roles of team members and the work performed by each member are defined by the physician. The interdisciplinary model demands a shift toward shared leadership,15 which promotes mutual problem-solving, open communication among all team members, and team cohesiveness. Undoubtedly, most organizations will still be inclined to identify a physician as team leader, but the nature of that leadership role must evolve from the traditional physician leadership role.
The DCCT provided a demonstration of such a change. Initially, the physicians were the primary diabetes care givers and directed the day-to-day activities of other team members by assigning tasks and responsibilities. As the study progressed, however, the physicians role developed into that of team builder, with emphasis on development of ideas, cohesiveness, and problem-solving skills.16
Santiago noted that the role of physicians in a diabetes treatment team should change and that teams should be available to the wider health care system. In his words, the physician should be "a team manager who could be replaced without dissolving the existing team. Indeed, the team could be organized so that it would serve the needs of many physicians, not just the manager, in a given community."16 Such a circumstance has long been standard in physical medicine and rehabilitation.
In the interdisciplinary model, registered nurses frequently assume the role of care coordinator. In other words, although physicians are responsible for the overall medical management of patients and are the primary providers for acute medical problems, the day-to-day management of the diabetes regimen can be provided by nurses.
In the DCCT, patients spent more than 80% of their time during follow-up visits with nonphysician health care professionals. Patients spent about 60% of their time with nurses.
Responsibilities of diabetes nurse clinicians include but need not be limited to providing diabetes education, assisting in the choice of insulin regimen, adjusting insulin dosages, teaching patients problem-solving skills, helping patients work through self-management problems, and developing educational and motivational strategies to promote patients independent self-management. Coordina-tors are the contact point for care, integrating the unique expertise of other disciplines to address patients needs. The role of nurses extends beyond the clinic or hospital. Nurses monitor patients diabetes management and achievement of treatment goals and provide ongoing communication between patients and the wider diabetes management team.
The role of dietitians goes beyond the identification of an appropriate meal plan. Working individually with patients to design meal algorithms, dietitians highlight appropriate and realistic nutrition and exercise goals, negotiate dietary strategies, and provide ongoing patient support, tailoring programs to meet patients lifestyle, motivation, and specific needs. Dietary counseling may include teaching an individual alteration of insulin doses for varying food intake.3,17 Ongoing dietitian contact is critical; it is inappropriate to restrict dietitian contact to times when a crisis requires diet modification.
Behavioral scientists (psychologists, social workers, psychiatrists, or other mental health professionals) play a pivotal role on the team by identifying barriers to diabetes self-management, providing assistance in setting treatment goals, and helping patients implement the management skills needed for intensive diabetes treatment. Behavioral scientists also provide counseling services regarding adjustment to chronic illness and stress management, diagnose psychiatric illness, and screen for learning disorders that might interfere with patient comprehension and compliance.
Having a shared professional identity does not suggest that members give up their unique contributions as physician, nutritionist, nurse, or behavioral scientist. Rather, all members bring specific expertise and a valuable point of view to the group. It does, however, call for tolerance and even encouragement of flexible roles within a team.
One example of nontraditional roles within a team setting would be having insulin adjustments made by a nurse, dietitian, or patient, rather than by a physician.18 Routine physical examinations and screening for complications may be provided by a nurse or medical assistant.18-20 This does not suggest that team members exceed their scope of practice, but it does require that all members have a thorough understanding of diabetes and its management, be skilled in helping patients identify barriers to self-management, and be willing to review competencies periodically.
Conflicting viewpoints on how to define health and illness stemming from different professional paradigms could undermine attempts to develop an integrated, interdisciplinary program.21 Teams can identify and address these core conflicts to develop an effective team paradigm. Nevertheless, the blurring of traditional roles permits greater flexibility within the team and should help make optimum use of health care resources.
The successful shift from consultative, multidisciplinary practice to collaborative, interdisciplinary practice requires that members of the team understand the unique nature of each discipline represented on the team and respect each disciplines unique input in decision making.22 Collaborative practice allows matching of provider expertise and style to specific patient needs and goals.
If optimal glucose control of a patients type 2 diabetes is achieved through diet alone, then the dietitian could be that patients primary provider. In this situation, the dietitian would be responsible for assuring that all standards of diabetes care are met for that patient, for coordinating the appropriate referrals to do so, and for providing the expert advice on dietary intervention for diabetes self-management.
Similarly, in patients for whom chronic diabetes complications have become the focus of treatment (painful, peripheral neuropathy, for example) medical/pharmaceutical intervention may become the focus, and the principal provider may be the physician or pharmacist. Likewise, if barriers to achieving diabetes care goals are psychosocial in nature, then visits with an appropriate expert in behavior modification or stress management may be more helpful than repeated trips to the doctor for a review of blood glucose levels.
The structure of the interdisciplinary team in the DCCT provided a framework for addressing progress toward goals. The study group encouraged each clinic treatment team to review all aspects of intensive diabetes management when participants were unable to reach the glycemic target. The six areas each team was challenged to review included patient/ team interactions, dietary issues, appropriateness of insulin regimen, psychosocial issues, technical proficiency issues, and clinic structure. These periodic reviews, conducted during routine staff meetings, allowed all team members to identify problems, collaborate on strategies to promote euglycemia while preventing hypoglycemia, and mutually agree upon staff-identified priorities that could then be shared or negotiated with each patient.
Outcome Associated With Team Management
The interdisciplinary model present at the end of the study evolved over time, with the recognition that optimal application of intensive diabetes management required a range of knowledge, skill, and enthusiasm that is rarely found in one person.16 Roles and function evolved, as did respect for the unique input brought by professionals from each discipline.
It is important to note that, by the end of the study, the majority of the care was delivered by nonphysician providers,16 which is now deemed appropriate for diabetes management.26 This development provides evidence for the benefits of team care as it pertains to attaining clear metabolic outcomes.
The benefits of interdisciplinary team care for people with diabetes was demonstrated by Halter and associates in 1993.27 Elderly patients with diabetes were randomly assigned to participate either in an intensive insulin treatment programwhich included insulin management aimed at specific blood glucose targets, a comprehensive diabetes education program and a program for social supportor to continue to receive standard diabetes care from their usual community resources. Subjects assigned to the intensive treatment group were able to significantly improve their glycemic control as compared to the standard care group.
Similar beneficial effects of an integrated, interdisciplinary approach to chronic disease management have been demonstrated with conditions other than diabetes. These include but are by no means limited to chronic pain, rheumatoid arthritis, chronic fatigue syndrome, mental illness, and care of the frail elderly.7-11,27,28
In two non-randomized studies of chronic pain, interdisciplinary pain management led to an improved sense of control over pain and decreased perceptions of pain as interfering with activities of daily living. These benefits were achieved despite no lessening of pain perception scores.10,28
Another non-randomized study of injured workers with chronic pain had similar findings. In addition, workers who participated in the interdisciplinary pain program were more likely to be able to return to work compared to workers who did not receive pain management services through the program. Early entry into the program (<1 year after injury) was associated with more favorable outcomes.28
Integrated care in people with severe mental illness has also been shown to be beneficial as compared to traditional intervention models. Participants in integrated, interdisciplinary programs were more likely to have worked for pay, more likely to have remained in treatment, had shorter and less frequent hospitalizations, had greater social support, and had greater client and family satisfaction than did subjects in more traditional care models.8,9
Scenario: A 50-Year-Old Woman With Diabetic Neuropathy
Part 1: Traditional model of diabetes treatment
The patient told the neurologist that she did not have diabetes. Her prescribed medications included glyburide and acetaminophen with codeine. The patient consulted with her primary care doctor, who in-formed her that she indeed had diabetes and that she was started on glyburide 2 years earlier for this reason.
When she had visited the doctor 2 years earlier, the doctor had told D.L. that she had a "high blood sugar level," but did not specifically use the term diabetes. Although she had continued to see her primary care doctor regularly, D.L. was never given a diet or exercise plan, and received no diabetes education.
D.L. was also a smoker, and she did not exercise regularly.
Part 2: Team management of diabetes
On arrival at the clinic, D.L. had an HbA1c level of 9.0% and microalbuminuria. She was considering applying for disability because of her painful neuropathy.
After the initial evaluation, D.L. agreed to work closely with the dietitian on a negotiated dietary program using carbohydrate counting. She received SMBG training and was asked to fax her blood glucose test results to the nurse every week. The nurse would share D.L.s blood glucose results with other team members in a weekly meeting. The social worker discussed the issue of disability with D.L. and her husband. A follow-up appointment was scheduled for 1 month.
Follow-up interventions. At the 1-month follow-up visit, D.L. met with the dietitian, social worker, and nurse before meeting with the physician. While indicating that she understood the dietary recommendations and had worked hard to incorporate dietary changes, she reported that she was following them about 60% of the time. She also reported that she checked her blood glucose levels 3 times per day, with an average mean blood glucose of 170 mg/dl. The issue of disability had been postponed, as the painful neuropathy was considerably improved. The physician discussed target blood glucose levels for her next visit, as well as the need to change D.L.s medication to improve her glycemic control.
The dietitian coordinated D.L.s care through frequent telephone contacts and communicated the information to the team at weekly meetings.
Outcome. Over the next 6 months, D.L. was started on lispro insulin before meals, with NPH insulin in the morning. The care coordinator role was shifted from the dietitian to the nurse after D.L. and the dietitian determined that dietary interventions were being followed about 70% of the time. (Her target was 80% compliance with the meal plan.) D.L.s HbA1c level decreased to 7.3%, with an average SMBG reading of 148 mg/dl. D.L. did not pursue an application for disability and decided to enter a smoking cessation program with the help of the social worker. She is now seen at quarterly visits with the diabetes care team.
Now that diabetes experts agree that metabolic control matters, early diagnosis of diabetes with aggressive treatment designed to achieve and maintain near-normal blood glucose control is imperative. Achieving these goals requires a better approach to diabetes treatment. It has been 15 years since team care was identified as a concept whose time had come for the management of diabetes,29 yet a team approach to diabetes care is still a rarity.
Ongoing treatment of diabetes by a multidisciplinary team is feasible and facilitates the achievement of treatment goals that will result in the development of fewer long-term diabetic complications. Achieving these goals does not seem possible using traditional models of care. There is no excuse for delay. We must transform team care from an abstract concept to a common practice.
1American Diabetes Association: Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care 20:1183-97, 1997.
2American Association of Diabetes Educators: The scope of practice for diabetes educators and the standards of practice for diabetes educators. Diabetes Educ 18:52-56, 1992.
3The DCCT Research Group: The effect of intensive treatment of diabetes on the development and progression of long term complications of insulin dependent diabetes mellitus. N Engl J Med 14:977-86, 1993.
4Fisher EB Jr, Heins JM, Hiss RG, Lorenz RA, Marrero DG, McNabb WL, Wylie-Rosett J: Metabolic Control Matters: Nationwide Translation of the Diabetes Control and Complication Trial: Analysis and Recommendations. Bethesda, Md., National Institutes of Health, 1993.
5American Diabetes Association: Standards of medical care for patients with diabetes mellitus. Diabetes Care 21 (Suppl. 1):S5-12, 1998.
6The DCCT Research Group: Implementation of treatment protocols in the Diabetes Control and Complications Trial. Diabetes Care 18:361-73, 1995.
7Eng C, Pedulla J, Eleazer GP, McCann R, Fox N: Program of all-inclusive care for the elderly (PACE): an innovative model of integrated geriatric care and financing. J Am Geriatric Soc 45:223-32, 1997.
8Chandler D, Meisel J, Hu TW, McGowen M, Mintz J, Madison K: Client outcomes in a three-year controlled study of an integrated service agency model. Psych Serv 47:1337-43, 1996.
9Chandler D, Meisel J, McGowen M, Mintz J, Madison K: Client outcomes in two model capitated integrated service agencies. Psych Serv 47:175-80, 1996.
10Lynch RT, Agre J, Powers JM, Sherman J: Long-term follow-up of outpatient interdisciplinary pain management with a no-treatment comparison group. Am J Phys Med Rehabil 75:213-22, 1996.
11Eaton KK: Cognitive behavior therapy for the chronic fatigue syndrome: use and interdisciplinary approach. Br Med J 312:1097-98, 1996.
12American Diabetes Association: Direct and Indirect Cost of Diabetes in the United States in 1992. Alexandria, Va., American Diabetes Association, 1993.
13American Association of Diabetes Educators: Position statement: Diabetes Control and Complications Trial (DCCT). Diabetes Educ 20:106-108, 1994.
14Goshorn J, Byers JF: CORE characteristics for survival in patient care redesign. AACN Clin Issues 8:236-45, 1997.
15Funnell MM: Integrated approaches to the management of NIDDM patients. Diabetes Spectrum 9:55-59, 1996.
16Santiago JV: Perspectives in diabetes: lessons from the Diabetes Control and Complications Trial. Diabetes 42:1549-54, 1993.
17Hollander P, Castle G, Callahan P, Olson B, Nelson J, Joynes J: Teaching patients self-management skills for intensive insulin therapy (Abstract). Diabetes 42 (Suppl 1):152A, 1993.
18The DCCT Research Group: Resource utilization and costs of care in the Diabetes Control and Complications Trial. Diabetes Care 18:1468-78, 1995.
19Dawson LY: DCCT: Team approach takes center stage. Diabetes Spectrum 6:222-24, 1993.
20Dawson LY: DCCT and primary care: prescription for change. Clin Diabetes 11:88-90, 1993.
21Vinicor F: Interdisciplinary and intersectoral approach: a challenge for integrated care. Patient Educ Counsel 26:267-72, 1995.
22Stubblefield C, Houston C, Haire-Joshu D: Interactive use of models of health-related behavior to promote interdisciplinary collaboration. J Allied Health 23:237-43, 1994.
23Herman WH, Dasbach EJ, Songer TJ, Thomson DE, Crofford OB: Assessing the impact of intensive insulin therapy on the health care system. Diabetes Rev 2:384-88, 1994.
24Dasbach EJ: Can quality care be planned? Diabetes Care 17 (Suppl 1):18-21, 1994.
25The DCCT Research Group: DCCT Manual of Operations. Springfield, Va. Department of Commerce, National Technical Information Service, 1993. Publication no. 93-183382.
26Eastman RC, Siebert CW, Harris M, Gorden P: Implications of the Diabetes Control and Complications Trial. J Clinical Endocrinol Metab 77:1105-1107, 1993.
27Flavell HA, Carrafa GP, Thomas CH, Disler BP: Managing chronic back pain: impact of an interdisciplinary team approach. Med J Aust 165:253-55, 1996.
28Jankus WR, Park TJ, Vankeulen M, Weisensel M: Interdisciplinary treatment of the injured worker with chronic pain: long-term efficacy. Wis Med J 94:244-49, 1995.
29Anderson RM: The team approach to diabetes: an idea whose time has come. Occupational Health Nurs 30:13-14; 66, 1982.
Meg Bayless, BSN, RN, CDE, is a nurse clinical specialist at the University of Iowa in Iowa City. Cathy Martin, MS, RN, CDE, is a clinical nurse coordinator at the University of Michigan in Ann Arbor.
Note of disclosure: Ms. Martin has received honoraria for speaking engagements from Eli Lilly and Co., which manufactures lispro insulin.
Copyright © 1997 American Diabetes Association
Last updated: 12/97