TEAM APPROACH IN DISEASE

MANAGEMENT ILLUSTRATED WITH

DIABETES

TEAM APPROACH TO PATIENT MANAGEMENT

Working as a team in the delivery of health services is a cornerstone of primary health care and one of the greatest benefits of working in a remote and rural context.

Health teams are composed of members from different healthcare professions with specialised skills and expertise, who communicate and collaborate to plan and provide quality health services.

MODELS OF TEAM PRACTICE

Collaborative team practice can be articulated in a number of ways.

It is important to understand the different models of team practice and the attributes and functions attached to each.

INTERDISCIPLINARY APPROACH

This approach expands the multidisciplinary team through collaborative communication (rather then shared communication) and interdependent practice.

Members contribute their own profession specific expertise, but collaborate to interpret findings and develop a care plan.

Team members negotiate priorities and agree by consensus.

The analogy of the hand is appropriate: individual digits of differing ability, function and dexterity work together to achieve more than the sum of the individual fingers.

This is also called interprofessional practice. Palliative care is a recognized model of

Interdisciplinary Practice

TRANSDISCIPLINARY TEAM APPROACHES The transdisciplinary team model values the

knowledge and skill of team members. Members of the transdisciplinary team share

knowledge, skills, and responsibilities across traditional disciplinary boundaries in assessment, diagnosis, planning and implementation.

Transdisciplinary teamwork involves a certain amount of boundary blurring between disciplines and implies cross-training and flexibility in accomplishing tasks.

Transdisciplinary practice becomes especially relevant in the remote and rural context, where health professionals need to be more flexible about their roles and responsibilities

TRANSDISCIPLINARY TEAM

The transdisciplinary team model is seen as a family friendly approach, operating within a family centred practice model.

Families are always members of the team and are respected and valued as equal members.

Although all team members participate equally, the family is the final decision maker.

MULTIDISCIPLINARY TEAM APPROACH

This utilises the skills and experience of individuals from different disciplines, with each discipline approaching the patient from their own perspective.

Each team member conducted separate assessment, planning and provision with varying degrees of coordination.

The team, directly or indirection, shares information regarding the patient and discuss future directions for patient care, and consequently relies on a good communication system (e.g. team meetings, case conferences etc).

Essentially health professionals work in conjunction with each other, but act autonomously.

This is also called multiprofessional practice. A typical example is seen in diabetes management

THE NEED FOR TEAM CARE IN DIABETES MANAGEMENT Diabetes management requires

expertise from many disciplines for optimal care

Team care is integral to health care reform initiatives geared towards improved quality and costs for diabetes care

BENEFITS OF TEAM CARE

Reduced risk factors for diabetes

Improved diabetes management

Lowered risk for complications

Lfficient patient educationAllowed each professional to

share different areas of expertise while standardizing systems

Clinical staff can become more specialized in effective DM management.

Enhanced opportunities for higher level training

Improved glycemic control

Increased patient follow-up

Higher patient satisfaction

Improved quality of life

Reduced hospitalizations

Decreased health care costs

DISADVANTAGES OF THE TEAM APPROACH

Administrative and medical staff leadership must see this as a priority, devote resources

Does not change culture to become more focused on diabetes hospital-wide

THE BASICS OF TEAM CARE

Select a key person to coordinate Vary team according to patients’

needs/load, organizational constraints, resources, clinical setting, geographic location and professional skills

Augment team with community resources and support

Expand access to team care via nontraditional approaches

WHAT MAKES A SUCCESSFUL TEAM?

Commitment/support of organizational leadership Active patient and health care professional

participation Information tracking system Adequate resources Payment mechanisms for team care services Coordinated communication system between team

members Documentation and evaluation of outcomes and

adjustment of services Effective identification of hyperglycemic patients

early in the stay, to allow the team to manage the care

Systematic continuous education throughout the institution – combination of didactics, online learning, bedside rounds, etc.

DIAGNOSIS AND MANAGEMENTOF DIABETES:

ILLUSTRATING TEAM CARE

GLUCOSE TESTING AND INTERPRETATION: DIAGNOSTIC

CRITERIATest Result Diagnosis

FPG, mg/dL(measured after 8-hour fast)

≤99 Normal

100-125 Impaired fasting glucose

≥126Diabetes

Confirmed by repeat testing on a different day

PPG, mg/dL(measured with an OGTT performed 2 hours after 75-g oral glucose load taken after 8-hour fast)

≤139 Normal

140-199 Impaired glucose tolerance

≥200Diabetes

Confirmed by repeat testing on a different day

Random plasma glucose, mg/dL

With polyurea, polydipsia, or polyphagia

≥200 Diabetes

Hemoglobin A1C, %(screening only)

≤5.4 Normal

5.5-6.4 High risk/prediabetes

≥6.5

DiabetesConfirmed by repeat testing

of FPG or PPG on a different day

GLUCOSE TESTING AND INTERPRETATION: DIAGNOSTIC CRITERIA

Test Result Diagnosis

Hemoglobin A1C, %

≤5.6 Normal

5.7-6.4 High risk/prediabetes

≥6.5

DiabetesConfirmed by repeat testing in absence of unequivocal

hyperglycemia

FPG, mg/dL

≤99 Normal

100-125 Impaired fasting glucose

≥126

DiabetesConfirmed by repeat testing in absence of unequivocal

hyperglycemia

PPG, mg/dL(measured with an OGTT performed 2 hours after 75-g oral glucose load)

≤139 Normal

140-199 Impaired glucose tolerance

≥200

DiabetesConfirmed by repeat testing in absence of unequivocal

hyperglycemiaRandom plasma glucose, mg/dL, with polyurea, polydipsia, or polyphagia

≥200 Diabetes

GDM All pregnant women should be screened

for GDM at 24-28 weeks of gestation, using a 75-g 2-h OGTT

In pregnancy, criteria for a diagnosis of gestatational diabetes mellitus (GDM)elevated plasma glucose levels (FPG levels

> 92 mg/dLone hour post-challenge ≥180 mg/dL; or

two hours ≥153 mg/dL)

RECOMMENDATIONS FOR A1C TESTING

A1C should be considered an additional optional diagnostic criterion, not the primary criterion for diagnosis of diabetes

When feasible, AACE/ACE suggest using traditional glucose criteria for diagnosis of diabetes

A1C is not recommended for diagnosing type 1 diabetes

A1C is not recommended for diagnosing gestational diabetes

RECOMMENDATIONS FOR A1C TESTING

A1C levels may be misleading in several ethnic populations (for example, African Americans)

A1C may be misleading in some clinical settings Hemoglobinopathies Iron deficiency Hemolytic anemias Thalassemias Spherocytosis Severe hepatic or renal disease

AACE/ACE endorse the use of only standardized, validated assays for A1C testing

GLYCAEMIC MANAGEMENT IN TYPE 2

DIABETES

BASIC PREMISE: BEYOND A SIMPLE FOCUS ON GLYCEMIC CONTROL

“…although glycemic control

(hemoglobin A1c [A1C], postprandial

glucose excursions [PPG], fasting plasma

glucose [FPG], glycemic variability)

parameters have an impact on coronary

heart disease (CVD) risk, mortality, and

quality of life, there are other factors that

also affect clinical outcomes in people

with diabetes.”

COMPREHENSIVE DIABETES CARE: TREATMENT GOALS, CONT’D.

Parameter Treatment Goal

Lipids (mg/dL)

LDL-C ≤ 70 highest risk; <100 high risk

non-HDL-C < 100 highest risk; <130 high risk

apolipoprotein B levels <80 highest risk; <90 high risk

HDL-C > 40 in men; > 50 in women

Triglycerides < 150

Blood Pressure (mm Hg)

Systolic 130

Diastolic 80

COMPREHENSIVE DIABETES CARE: TREATMENT GOALS, CONT’D

Parameter Treatment Goal

Weight

Weight loss Reduce by at least 5-10%; avoid weight gain

Anticoagulant Therapy

Aspirin For secondary CVD prevention or primary prevention for very high risk patients

CREATING A DIABETES TEAM• Diabetes is a complex disease

requiring continuous lifetime management.

• The aim of a team of diabetes specialists is to support the patient and the primary health care provider in long-term efforts to achieve and maintain glycaemic control.

CORE DIABETES TEAM

Patient: The patient is the most critical diabetes team member. Successful management depends on the patient’s level of involvement. In children and adolescents with diabetes, parents or caregivers serve as primary team members.

Primary health care provider: One member of the management team should act as leader, coordinating all elements of the management plan and communicating with other team members. Often the primary care physician will fulfill this role. In other cases, it will be carried out by an endocrinologist, internist, certified diabetes educator, nurse practitioner, or physician assistant.

Certified diabetes educator: Diabetes education and support is critical to effective self-management. Diabetes educators teach patients about nutrition, exercise, medication, and glucoseand ketone monitoring, as well as how to deal withpsychological issues related to diabetes.

Registered dietitian: The nutritional needs of the patient with diabetes can be complex. Weight reduction is often a significant element of the management plan. A registered dietitian specializing in diabetes is a key member of the management team

Advanced practice health care provider: Nurse practitioners and physician assistants with specialized training in diabetes management may serve as valuable members of the diabetes team by providing enhanced medical care and follow-up evaluation to patients.

Additional diabetes team members may include pharmacists, exercise physiologists, mental health professionals, registered nurses(RNs), licensed practical nurses (LPNs), and school nurses.

IMPLEMENTATION OF A DIABETES COMPREHENSIVE CARE PLAN

REQUIRES A MULTIDISCIPLINARY TEAM

APPROACH

Endocrinologist

Primary care physician

Physician’s assistant

Nurse practitioner

Registered nurse

Certified diabetes educator

Dietitian

Exercise specialist

Mental healthcare

professional

Patient Pharmacist

School Nurses and Licensed

Practical Nurse

DIABETES SELF-MANAGEMENT EDUCATION: THERAPEUTIC LIFESTYLE MANAGEMENT

medical nutrition therapy physical activityavoidance of

tobacco

products

adequat

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and quality of

sleep

DIABETES COMPREHENSIVE CARE PLAN

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Comprehensive diabetes self-education for the patient

Therapeutic lifestyle change

Comprehensive Care Plan

GLYCAEMIC MANAGEMENT IN TYPE 2 DIABETES

Therapeutic Lifestyle Change

COMPONENTS OF THERAPEUTIC LIFESTYLE CHANGE

Healthful eating Sufficient physical activity Sufficient amounts of sleep Avoidance of tobacco products Limited alcohol consumption Stress reduction

AACE HEALTHFUL EATING RECOMMENDATIONSTopic RecommendationGeneral eating habits

Regular meals and snacks; avoid fasting to lose weight Plant-based diet (high in fiber, low calories/glycemic index and high in

phytochemicals/antioxidants) Understand Nutrition Facts Label information Incorporate beliefs and culture into discussions Informal physician-patient discussions Use mild cooking techniques instead of high-heat cooking

Carbohydrate Explain health effects of the 3 types of carbohydrates: sugars, starch, and fiber Specify healthful carbohydrates (fresh fruits and vegetables, pulses, whole

grains) and target 7-10 servings per day Lower-glycemic index foods may facilitate glycemic control*: multigrain bread,

pumpernickel bread, whole oats, legumes, apple, lentils, chickpeas, mango, yams, brown rice

Fat Specify healthful fats: low mercury/contaminant-containing nuts, avocado, certain plant oils, fish

Limit saturated fats (butter, fatty red meats, tropical plant oils, fast foods) and trans fat

Use no- or low-fat dairy products Protein Consume protein from foods low in saturated fats (fish, egg whites, beans)

Avoid or limit processed meatsMicronutrients Routine supplementation is not necessary except for patients at risk of

insufficiency or deficiency Chromium; vanadium; magnesium; vitamins A, C, and E, and CoQ10 are not

recommended for glycemic control

*Insufficient evidence to support a formal recommendation to educate patients that sugars have both positive and negative health effects

MEDICAL NUTRITIONAL THERAPY RECOMMENDATIONS

Consistency in day-to-day carbohydrate intake Adjusting insulin doses to match carbohydrate

intake (eg, use of carbohydrate counting) Limitation of sucrose-containing or high-

glycemic index foods Adequate protein intake “Heart healthy” diets Weight management Exercise Increased glucose monitoring

PHYSICAL ACTIVITY RECOMMENDATIONS

≥150 minutes per week of moderate-intensity exercise Flexibility and

strength training Aerobic exercise (eg,

brisk walking) Start slowly and

build up gradually

Evaluate for contraindications and/or limitations to increased physical activity before patient begins or intensifies exercise program

Develop exercise recommendations according to individual goals and limitations

GLYCEMIC MANAGEMENT IN TYPE 2 DIABETES

Antihyperglycemic Therapy

PATHOPHYSIOLOGY OF T2DM

Organ System DefectMajor RolePancreatic beta cells Decreased insulin secretion

Muscle Inefficient glucose uptake

LiverIncreased endogenous glucose secretion

Contributing RoleAdipose tissue Increased FFA productionDigestive tract Decreased incretin effectPancreatic alpha cells Increased glucagon secretion

Kidney Increased glucose reabsorptionNervous system Neurotransmitter dysfunction

NONINSULIN AGENTS AVAILABLE FOR THE

TREATMENT OF TYPE 2 DIABETES

Class Primary Mechanism of Action Agent Available as-Glucosidase inhibitors

Delay carbohydrate absorption from intenstine

Acarbose Precose or generic

Miglitol Glyset

Amylin analog

Decrease glucagon secretion

Slow gastric emptying Increase satiety

Pramlintide Symlin

Biguanide Decrease HGP Increase glucose uptake

in muscleMetformin Glucophage or

generic

Bile acid sequestrant

Decrease HGP? Increase incretin levels?

Colesevelam WelChol

DPP-4 inhibitors

Increase glucose-dependent insulin secretion

Decrease glucagon secretion

Linagliptin TradjentaSaxagliptin Onglyza

Sitagliptin Januvia

Dopamine-2 agonist

Activates dopaminergic receptors

Bromocriptine Cycloset

NONINSULIN AGENTS AVAILABLE FOR THE TREATMENT OF TYPE 2 DIABETES

Class Primary Mechanism of Action Agent Available as

Glinides Increase insulin

secretionNateglinide Starlix or

genericRepaglinide Prandin

GLP-1 receptor agonists

Increase glucose-dependent insulin secretion

Decrease glucagon secretion

Slow gastric emptying Increase satiety

Exenatide Byetta

Exenatide XR Bydureon

Liraglutide Victoza

Sulfonylureas Increase insulin

secretion

Glimepiride Amaryl or generic

Glipizide Glucotrol or generic

Glyburide

Diaeta, Glynase, Micronase, or generic

Thiazolidinediones

Increase glucose uptake in muscle and fat

Decrease HGP

Pioglitazone Actos

Rosiglitazone* Avandia

*Use restricted due to increased risk of myocardial infarction (MI)

INSULINS AVAILABLE FOR THE TREATMENT OF TYPE 2 DIABETES

ClassPrimary Mechanism of Action Agent Available as

Insulin Increase glucose

uptake Decrease HGP

Basal

Detemir LevemirGlargine LantusNeutral protamine Hagedorn (NPH)

Generic

Prandial

Aspart NovoLogGlulisine ApidraLispro HumalogRegular human Humulin

Premixed

Biphasic aspart NovoLog Mix

Biphasic lispro Humalog Mix

COMBINATION AGENTS AVAILABLE FOR THE TREATMENT OF TYPE 2 DIABETES

Class Added Agent Available as

Metformin + DPP-4 inhibitorLinagliptin JentaduetoSaxagliptin Kombiglyze XRSitagliptin Janumet

Metformin + glinide Repaglinide Prandimet

Metformin + sulfonylureaGlipizide

Metaglip and generic

GlyburideGlucovance and generic

Metformin + thiazolidinedione

Pioglitazone ACTOplus MetRosiglitazone* Avandamet

Thiazolidinedione + sulfonylurea

Pioglitazone DuetactRosiglitazone* Avandaryl

*Use restricted due to increased risk of myocardial infarction (MI)

FIRST PRINCIPLES OF THE DIABETES CARE ALGORITHM

Avoidance of hypoglycemia is a priority Avoidance of weight gain is a priority All medication options need to be

considered Acquisition cost is not the total cost of a

drug Therapy selection must be stratified by

A1C Post-prandial glucose is an important

target

SECONDARY PRINCIPLES OF THE DIABETES CARE ALGORITHM

Ease of use improves adherence

Minimal side effects improves adherence

Improved -cell performance over a longer period of time is possible

Multiple combinations are required

DIABETES CARE ALGORITHM: OVERVIEW

Stratify treatment based on initial A1C level

Initial monotherapy for A1C 6.5% - 7.5%

Initial dual therapy for A1C 7.6% - 9.0%

Initial triple therapy or insulin for A1C >9.0%

Monitor A1C carefully and intensify therapy at 2- to 3-month intervals if A1C goal not achieved Monotherapy → dual

therapy Dual therapy → triple

therapy or insulin ± oral agents

Combine agents with different mechanisms of action

CONCLUSION Team approach provides positive measurable

outcomes. With a diverse group of healthcare professionals,

such as physicians, nurses, pharmacists, dieticians, and health educators with the patient at the center of the team, the team can ensure treatment goals are maintained for chronic diseases.

The team approach implements: Patient satisfaction and self-management Development of a community support network Team coordination Team communication Patient follow-up Use of protocols and other tools Use of computerized information systems, and outcome

evaluations

CONCLUSION Team approach encourages patient partnerships with a view to motivating and empowering individuals with diabetes to take control of their condition and ultimately bring to bear improved glycaemic control and better quality of life.