Team-based Care

About Team-based care

Managing complex conditions like diabetes or heart disease requires a wide range of knowledge and expertise. Team-based care is a patient-centered approach where the primary care physician serves as the coordinator, and other health care professionals offer support as team members. The care team may include:

• Nurse
• Dietitian
• Pharmacist
  • Resources for Pharmacists
• Certified Diabetes Educator (CDE)
• Social worker
• Clinical specialist
• Community health worker, care navigator, interpreter
• Dental therapist
• Dental hygienist

Evidence supports team-based care, showing:

• Improved quality of care and use of evidence-based guidelines
• Better patient engagement and treatment adherence
• Improved blood pressure control
• Improved diabetes management that can lower the risk for diabetes complications
• Better medication management, patient follow-up and self-management support

Resources

• Core Principles & Values of Effective Team-Based Health Care (PDF)
• Team-Based Care: Optimizing Primary Care for Patients and Providers
• A Team-Building Model for Team-Based Care
• The Community Guide: Team-Based Care to Improve Blood Pressure Control
• The Patient-Centered Medical Home Model 
• Redesigning the Health Care Team: Diabetes Prevention and Lifelong Management (PDF)