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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 education
Allowed 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 MANAGEMENT


OF DIABETES: ILLUSTRATING
TEAM CARE

GLUCOSE TESTING AND INTERPRETATION:


DIAGNOSTIC CRITERIA
Test

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

PPG, mg/dL
(measured with an OGTT
performed 2 hours after 75g oral glucose load taken
after 8-hour fast)
Random plasma glucose,
mg/dL
With polyurea, polydipsia,
or polyphagia

Hemoglobin A1C, %
(screening only)

Result

Diagnosis

99

Normal

100-125

Impaired fasting glucose

126

Diabetes
Confirmed by repeat testing
on a different day

139

Normal

140-199

Impaired glucose tolerance

200

Diabetes
Confirmed by repeat testing
on a different day

200

Diabetes

5.4

Normal

5.5-6.4

High risk/prediabetes

6.5

Diabetes
Confirmed by repeat testing
of FPG or PPG on a
different day

GLUCOSE TESTING AND INTERPRETATION:


DIAGNOSTIC CRITERIA
Test

Result

Diagnosis

5.6

Normal

5.7-6.4

High risk/prediabetes

6.5

Diabetes
Confirmed by repeat testing
in absence of unequivocal
hyperglycemia

99

Normal

100-125

Impaired fasting glucose

126

Diabetes
Confirmed by repeat testing
in absence of unequivocal
hyperglycemia

139

Normal

140-199

Impaired glucose tolerance

200

Diabetes
Confirmed by repeat testing
in absence of unequivocal
hyperglycemia

200

Diabetes

Hemoglobin A1C, %

FPG, mg/dL

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

Random plasma glucose,


mg/dL, with polyurea,
polydipsia, or polyphagia

GDM

All pregnant women should be screened for


GDM at 24-28 weeks of gestation, using a 75g 2-h OGTT
In pregnancy, criteria for a diagnosis of
gestatational diabetes mellitus (GDM)
elevated

plasma glucose levels (FPG levels > 92

mg/dL
one 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, CONTD.
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, CONTD
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 patients 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 with
psychological 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

DIABETES SELF-MANAGEMENT EDUCATION:


THERAPEUTIC LIFESTYLE MANAGEMENT

DIABETES 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

Recommendation
AACE HEALTHFUL
EATING RECOMMENDATIONS
Regular meals and snacks; avoid fasting to lose weight

Topic
General eating
habits

Carbohydrate

Fat

Protein

Micronutrients

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
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
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
Consume protein from foods low in saturated fats (fish, egg whites, beans)
Avoid or limit processed meats
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 moderateintensity 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
Major Role
Pancreatic beta
cells
Muscle
Liver
Contributing Role
Adipose tissue
Digestive tract
Pancreatic alpha
cells
Kidney
Nervous system

Defect
Decreased insulin secretion
Inefficient glucose uptake
Increased endogenous glucose
secretion
Increased FFA production
Decreased incretin effect
Increased glucagon secretion
Increased glucose reabsorption
Neurotransmitter dysfunction

NONINSULIN AGENTS AVAILABLE FOR


THE TREATMENT OF TYPE 2 DIABETES
Class
-Glucosidase
inhibitors
Amylin analog

Biguanide
Bile acid
sequestrant
DPP-4
inhibitors
Dopamine-2
agonist

Primary Mechanism of Action


Delay carbohydrate
absorption from intenstine
Decrease glucagon secretion
Slow gastric emptying
Increase satiety
Decrease HGP
Increase glucose uptake in
muscle
Decrease HGP?
Increase incretin levels?
Increase glucose-dependent
insulin secretion
Decrease glucagon secretion
Activates dopaminergic
receptors

Agent
Acarbose
Miglitol

Available as
Precose or generic
Glyset

Pramlintide

Symlin

Metformin

Glucophage or
generic

Colesevelam

WelChol

Linagliptin
Saxagliptin
Sitagliptin

Tradjenta
Onglyza
Januvia

Bromocriptine Cycloset

NONINSULIN AGENTS AVAILABLE FOR


THE TREATMENT OF TYPE 2 DIABETES
Class

Primary Mechanism of Action

Glinides

Increase insulin secretion

Increase glucosedependent insulin


secretion
Decrease glucagon
secretion
Slow gastric emptying
Increase satiety

GLP-1 receptor
agonists

Agent
Nateglinide
Repaglinide

Available as
Starlix or generic
Prandin

Exenatide

Byetta

Exenatide XR

Bydureon

Liraglutide

Victoza

Glimepiride

Amaryl or generic
Glucotrol or
generic
Diaeta, Glynase,
Micronase, or
generic
Actos

Glipizide
Sulfonylureas

Increase insulin secretion


Glyburide

Thiazolidinediones

Increase glucose uptake


in muscle and fat
Decrease HGP

Pioglitazone

Rosiglitazone* Avandia

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

INSULINS AVAILABLE FOR THE


TREATMENT OF TYPE 2 DIABETES
Primary Mechanism of
Agent
Action
Increase glucose
Insulin
uptake
Decrease HGP
Detemir
Glargine
Basal
Neutral
protamine
Hagedorn (NPH)
Aspart
Glulisine
Prandial
Lispro
Regular human
Biphasic aspart
Premixed
Biphasic lispro
Class

Available as

Levemir
Lantus
Generic
NovoLog
Apidra
Humalog
Humulin
NovoLog Mix
Humalog Mix

COMBINATION AGENTS AVAILABLE FOR THE


TREATMENT OF TYPE 2 DIABETES
Class

Added Agent
Linagliptin
Saxagliptin
Sitagliptin
Repaglinide

Available as
Jentadueto
Metformin + DPP-4 inhibitor
Kombiglyze XR
Janumet
Metformin + glinide
Prandimet
Metaglip and
Glipizide
generic
Metformin + sulfonylurea
Glucovance and
Glyburide
generic
Pioglitazone
ACTOplus Met
Metformin + thiazolidinedione
Rosiglitazone* Avandamet
Pioglitazone
Duetact
Thiazolidinedione +
sulfonylurea
Rosiglitazone* 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

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.