Team-based care has been shown to improve outcomes for patients with diabetes compared to conventional care. Key members of the diabetes care team include nurses, registered dietitians, pharmacists, and community health workers. Technologies like telehealth, electronic health records, and dashboards help coordinate care and monitor patient populations. Community programs also support diabetes patients through services like the YMCA's diabetes prevention program.

1. Team as Treatment:
Driving Improvement in Diabetes
June 11, 2019 | 3 p.m. EST

2. Expert Panelists
Veena Channamsetty, MD
• Chief Medical Officer
Brian Austin
• Interim Director, MacColl Center for Health Care Innovation
Dipak Patel, MD
• Physician
Sarahi Almonte, RN-BSN, MS
• Nurse Manager
Rachel Drake, MS, RD, CSP, CNSC, CD-N
• Nutrition Manager

3. Disclosure
• With respect to the following presentation, there has been no relevant
(direct or indirect) financial relationship between the party listed above (or
spouse/partner) and any for-profit company in the past 12 months which
would be considered a conflict of interest.
• The views expressed in this presentation are those of the presenters and
may not reflect official policy of Community Health Center, Inc. and its
Weitzman Institute.
• We are obligated to disclose any products which are off-label, unlabeled,
experimental, and/or under investigation (not FDA approved) and any
limitations on the information hat we present, such as data that are
preliminary or that represent ongoing research, interim analyses, and/or
unsupported opinion.

4. Get the Most Out of Your Zoom Experience
• Use the Q&A Button to submit questions!
• Live tweet us at @CHCworkforceNCA
• Recording and slides are available after the
presentation on our website within one week
• View past webinars at www.chc1.com/nca

5. CHC Profile:
 Founding year: 1972
 Over 200 service sites
 Patients/year: 100,000
5

6. The Weitzman Institute works to improve primary care
and its delivery to medically underserved and special populations through research, innovation, and
the education and training of health professionals.
Weitzman Institute
6

7. Provides education, information, and training to interested
health centers on:
Transforming Teams
• National Webinars on the team
based care model
• Invited participation in Learning
Collaboratives to launch team
based care at your health center
Training the Next Generation
• National Webinar series on developing nurse
practitioner and clinical psychology residency
programs and successfully hosting health
profession students in health centers
• Invited participation in Learning Collaborative
to implement these programs at health center
National Cooperative Agreement
Clinical Workforce Development

8. Resource Highlights
National Learning Library
www.chc1.com/nca
February 15 | Taking Team-Based Care to the Next Level Video Slides
February 22 | Advancing the Practice of RNs and Behavioral Health Providers
Video Slides
February 27| The Vital Role of Behavioral Health: Effective Integration in a
Model of Team Based Care Slides
May 23 | Improving the Health Outcomes of Both Patients AND Populations. |
Video Slides

9. Learning Objectives
• Discuss evidence-based model for team-based care
• Define three extended team members who
contribute to reducing complications
• Identify three uses of technology to improve access
and quality of care
• Name two community based projects

10. Building Your Primary Care Team
To Transform Your Practice:
Learning from Effective Ambulatory Practices
MacColl Center for Health Care Innovation
Kaiser Permanente Washington
Health Research Institute
June 11, 2019
Brian Austin, Interim Director

11. Shojania, K. G. et al. JAMA 2006;296:427-440.
Meta-analysis of Interventions
to Improve Diabetes Care
CONCLUSION:
Most QI strategies produced small to modest improvements in glycemic control. Team
changes and case management showed more robust improvements, especially for
interventions in which case managers could adjust medications without awaiting
physician approval.

12. For Diabetics, Health Risks Fall Sharply 4/16/14
“Rates of all five [diabetes] complications declined between 1990 and
2010, with the largest relative declines in acute myocardial infarction
(−67.8%) and death from hyperglycemic crisis (−64.4%), followed by
stroke and amputations, which each declined by approximately half
(−52.7% and −51.4%, respectively); the smallest decline was in end
stage renal disease (−28.3%; 95% CI, −34.6 to −21.6).”*
WHY?
“An increased emphasis on the integrated management of care for
patients with chronic diseases, including enhancements in team-based
care, patient education, in disease management, and clinical decision-
making support”*
*Changes in Diabetes-Related Complications in the United States, 1990–2010 Gregg
et al, NEJM 2014; 370:1514-1523.

13. How do Teams Improve Outcomes?

14. www.improvingprimarycare.org

15. June 13, 2019

17. Where to find help to build your team
June 13, 2019

18. www.improvingprimarycare.org

19. Team-based care approach to Diabetes management has shown a positive impact
in improving patient outcomes in a number of studies over conventional
community care services.1
In the global Diabetes Attitude Wishes and Needs (DAWN) study, patients who
had access to diabetes team members, such as nurses, reportedly had better
outcomes.2,3
1 Pape, G. A., Hunt, J. S., Butler, K. L., Siemienczuk, J., LeBlanc, B. H., Gillanders, W., ... & Bonin, K. (2011). Team-based care approach to cholesterol
management in diabetes mellitus: two-year cluster randomized controlled trial. Archives of internal medicine, 171(16), 1480-1486.
2 Rubin R, Peyrot M, Siminerio L, Health care and patient-reported outcomes: Results of the cross-national diabetes attitudes, wishes and needs (DAWN)
study, Diabetes Care, 2006;29: 1249–55.
3 Siminerio L, Funnell M, Peyrot M, Rubin R, US nurses’ perceptions of their role in diabetes care: Results of the cross-national diabetes, attitudes, wishes and
needs (DAWN) study, Diabetes Educ, 2007;33:152–62.
System Redesign to Improve Outcomes

20. Diabetes Standards of Care
American Diabetes Association
American Diabetes Association’s Standards of Medical Care in Diabetes—2019. Diabetes
Care 2018;42(Suppl. 1):S1–S194. The complete 2019 Standards supplement, including all
supporting references, is available at professional.diabetes.org/ standards.

21. Diabetes Statistics
• 30.3 million Americans are diabetic
• 84.1 million Americans have prediabetes
• $237 billion a year are medical costs associated
with diabetes
• Diabetes causes $90 billion a year in lost
productivity
https://www.cdc.gov/chronicdisease/pdf/aag/ddt-H.pdf

22. UDS Data
Table: UDS National Report 2017 - Table 7 - Health Outcomes and Disparities
Medical Conditions (% of Patients with
Medical Conditions)
2017
Percentage of Diabetes Patients 14.98%
Number of Diabetes Patients 2,266,902
Percentage of Diabetic Patients with Poorly
Controlled Hemoglobin A1c (HbA1c > 9%) or No Test
During Year
32.95%
Number of Diabetic Patients with Poorly Controlled
Hemoglobin A1c (HbA1c > 9%) or No Test During Yea
746,932

23. Chronic Care Model
http://care.diabetesjournals.org/content/40/Supplement_1/S6
The CCM includes six core elements to optimize the care of patients with chronic disease:
• Delivery system design (moving from a reactive to
a proactive care delivery system where planned visits are
coordinated through a team-based approach)
•
• Self-management support
• Decision support (basing care on evidence-based, effective
care guidelines)
• Clinical information systems (using registries that can
provide patient-specific and population-based support to
the care team)
• Community resources and policies (identifying or
developing resources to support healthy lifestyles)
• Health systems (to create a quality-oriented culture)
Collaborative, multidisciplinary teams are best suited to provide care for people with chronic
conditions such as diabetes and to facilitate patients’ self-management.

24. • Hemoglobin A1C
• Diabetic Retinopathy
• Nephropathy
• Peripheral Neuropathy
• Blood Pressure
• Other: Planned Care
• Cervical cancer, breast
cancer, colon cancer
• Depression screening
• Dental screening
Screening and Monitoring

25.  Connecting the Care
• Administering
vaccines
• Alerting
registered nurse
for education
• Coordinating
referrals
Choreography of Care

26. • Education
• Self-management/goal
setting
• Motivational interviewing
• Identifying other key barriers
through SDOH screening
• Basal insulin titration
• Medication
reconciliation/adherence
Care Management

27. Prevention, Screening and Clinical Standards
Comprehensive Medical Evaluation
Diabetes diagnosis:
• A1c > 6.5%
• Fasting glucose > 125 mg / dl
• Random glucose > 200 mg / dl
• 2 hour glucose tolerance > 200 mg/dl
• Best to repeat test on a different day to confirm
Diabetes target in general:
• A1c < 7.0%
• Blood pressure control
• LDL control
Type 1 Diabetes, previously called “insulin-dependent diabetes” or “juvenile-onset diabetes,”
accounts for 5–10% of diabetes and is due to cellular-mediated autoimmune destruction of
the pancreatic β-cells.
Type 2 Diabetes, previously referred to as “non-insulin-dependent diabetes” or “adult-onset
diabetes,” accounts for ∼90–95% of all diabetes. Type 2 diabetes encompasses individuals
who have insulin resistance and usually relative (rather than absolute) insulin deficiency.

28. • Clinical lead and empowers the team
• Focus on the medical management of diabetes
• Assess patient readiness for treatment
• Templated visits for diabetes care
• Disease management and monitoring
• Cardiovascular risks
• Higher rate of depression
• Lipids
• Blood Pressure
• Dental
• Responding to positive screenings
• Appropriate referrals when needed
Comprehensive Medical Evaluation

29. Title Slide
Systems for Clinical Decision Support
The Planned Care Dashboard

30. Title Slide
Systems for clinical support and population management
Diabetes Dashboard

31. Treatment or Management
• Prevention
• Lifestyle interventions
• Medications
• Shared medical visit
• Referrals

32. Extended Team
Staff who have an ongoing professional
relationship with the core team and who
provide services to any patient of the
practice or specific sub-populations
• Pharmacist
• Chiropractor
• Dietitian
• Certified Diabetes Educator
• Community Health Worker
• Access to Care
• Podiatry
• Etc.
Telehealth
Health centers have increasingly
recognized the potential for
telehealth, in its various forms, to
address service and access gaps
resulting from provider shortages
• eConsults
• Synchronous
• Asynchronous

33. Polling Question
My health center has these team members
embedded on site (Check all that apply)
Certified Diabetes Educator
Podiatrist
Outreach Worker (Access to Care/Community Health Worker)
Dietitian

34. Extended Team Highlight: Dietitian

35. Lifestyle Medicine Practices
Lifestyle Medicine is the use of evidence-based lifestyle
therapeutic approaches, such as a predominantly whole foods,
plant based lifestyle, regular physical activity, adequate sleep,
stress management, avoiding use of risky substances to treat,
reverse and prevent chronic disease
• Often easily reversible within 2 to 4 weeks.
• Typical office visit is too short for meaningful engagement into
lifestyle medicine
• Most providers think patients will not change lifestyle
• Group visits gives provider the time to focus on lifestyle
• Informed Consent
Sources:
The American College of Lifestyle Medicine (ACLM), 2019, https://lifestylemedicine.org
Galaviz, K. I., Narayan, K. V., Lobelo, F., & Weber, M. B. (2018). Lifestyle and the prevention of Type 2 Diabetes: a status report. American journal of lifestyle
medicine, 12(1), 4-20.

36. Research
The American College of Lifestyle Medicine has direct links to dozens of original studies
from the 1970s onwards demonstrating that most patients with type 2 diabetes can get off
of medications fairly quickly by resolving the root cause of type 2 diabetes – insulin
resistance. Once the insulin resistance improves, the hyperglycemia resolves quickly.
• Research has clearly demonstrated that type 2 diabetes is primarily a lifestyle related
disease.
• Treatment with medications can control diabetes but not necessarily eliminate
complications, but also cause significant side effects.
• The same lifestyle medicine approach for diabetes is helpful for a wide spectrum of
diseases including hypertension, high cholesterol, obesity and cardiovascular disease.
• Wide spread use of lifestyle medicine could prevent, control or reverse about 80-90%
of cases of diabetes.
Source: The American College of Lifestyle Medicine (ACLM), 2019, https://lifestylemedicine.org

37. Research – Clinical Trials
Study 1
NIH funded study randomized 100 people to compare the effects of a standard ADA diet to a
primarily whole food plant based diet.
– A1c dropped from 8.0 to 6.8. ADA diet dropped from 8.0 to 7.6%.
– LDL drop 21% tvs 9%
– Wt dropped 14.3 lbs vs 6.8 lbs.
– Medications reduced or stopped 43% vs 26%
– No calorie or carb counting in the plant based group.
– 22 week trial
Source: Diabetes Care, 2006. 29(8): p. 1777-83
Study 2
Primary Care led weight management for remission of type 2 diabetes ( DiRect ) trial.
– Open-label, Cluster randomized trial.
– 306 people with type 2 diabetes
– 12 months intervention ( withdrawal of DM and HTN meds, meal replacement x 3 months, step food
reintroduction, structured support )
– Diabetes remission in 46% of the intervention group.
– 25% of participants lost 33 pounds or more in the 1 year. 86% remission.
Source: Lancet. 2018 Feb 10;39 p:541-551.

38. Examples of Lifestyle Medicine

40. Examples of Lifestyle Medicine in Action
• South Sacromento Kaiser Permanenete office . Dr. Rajiv
Misquitta, MD
• Bay Area Kaisre Permanente office. Dr. Pankoj Vij
• Progressive Health of Delaware. Dr. David Donahue,
MD https://www.progressivehealthproject.com/progressive-
health-of-delaware/
• Dean Ornish, MD http://deanornish.com/
• Caldwell Essylstyn, MD http://www.dresselstyn.com/site/
• Harvard University http://www.harvardlifestylemedicine.org/
• Bellevue Hospital Plant Based Lifestyle Medicine Clinic , NYC
• www.masteringdiabetes.org

41. SDOH Screening and Referrals
Some SDOH to Consider:
• Housing
• Utilities
• Access to Food
• Safety
Social determinants of health (SDOH) are conditions in the
environments in which people live, learn, work, play, worship, and
age that affect a wide range of health, functioning, and quality-of-life
outcomes and risks. SDOH contribute to 40-50% of health outcomes.
Sources: US Department of Health and Human Services. (2013). Healthy People 2020
topics and objectives. Washington, DC.
Artiga, S., & Hinton, E. (2018). Beyond health care: the role of social determinants in
promoting health and health equity. Health, 20, 10.

42. http://www.nachc.org/wp-content/uploads/2018/05/PRAPARE_One_Pager_Sept_2016.pdf
https://innovation.cms.gov/Files/worksheets/ahcm-screeningtool.pdf
Validated Screening Tools

43. Engage with community based agencies
• 211
• Food pantries
• Community Action Teams
• Community Collaboration Meetings
(Hospitals)
• School-Based Health Centers
Community
Community Health Outreach Workers:
• Access to Care
• Community Health Workers
Assessing and tracking community
resources available

44. YMCA’s Diabetes Prevention Program
The YMCAs DPP is part of the National Diabetes Prevention Program led by the
U.S. Centers for Disease Control and Prevention (CDC), is a lifestyle behavior
intervention program
• 58- to 71-percent reduction in the prevention or delay of new cases of type 2 diabetes in
adults over 60.
 Trained lifestyle coach facilitates a small group of participants in learning about healthier
eating, physical activity and other behavior changes.
 Program is designed to help participants adopt and maintain healthy lifestyle changes
over the course of one year.
 The program goals are (1) to lose 7% of your body weight and (2) gradually increase
physical activity to 150 min per weeks.
https://www.mrknewsroom.com/news-release/corporate-news/merck-foundation-grant-expands-ymcas-diabetes-
prevention-program-five-st

45. Conclusion
• Evidence supports the Chronic Care Model and a TBC approach
in diabetic patients
• ADA Guidelines recommend lifestyle interventions and Team
Based Care
• Defined roles and responsibilities of the team supports
efficient care delivery and improves patient outcome
• Identifying SDOH and partnering with community resources
can address patient care needs and improve health outcomes

46. Questions

47. Visit our National Learning Library
Contact us at nca@chc1.com
www.chc1.com/nca