title: Multidisciplinary team approach to improved chronic care management for diabetic patients in an urban safety net ambulatory care clinic.
abstract: Since the care of patients with multiple chronic diseases such as diabetes and depression accounts for the majority of health care costs, effective team approaches to managing such complex care in primary care are needed, particularly since psychosocial and physical disorders coexist. Uncontrolled diabetes is a leading health risk for morbidity, disability and premature mortality with between 18-31% of patients also having undiagnosed or undertreated depression. Here we describe a team driven approach that initially focused on patients with poorly controlled diabetes (A1c > 9) that took place at a family medicare office. The team included: resident and faculty physicians, a pharmacist, social worker, nurses, behavioral medicine interns, office scheduler, and an information technologist. The team developed immediate integrative care for diabetic patients during routine office visits.
authors.affiliation: Department of Family Medicine, Carolinas Healthcare System, Charlotte, NC 28207, USA. hazel.tapp@carolinashealthcare.org
authors.forename: Hazel
authors.initials: H
authors.lastname: Tapp
authors.forename: Shay E
authors.initials: SE
authors.lastname: Phillips
authors.forename: Dael
authors.initials: D
authors.lastname: Waxman
authors.forename: Matthew
authors.initials: M
authors.lastname: Alexander
authors.forename: Rhett
authors.initials: R
authors.lastname: Brown
authors.forename: Mary
authors.initials: M
authors.lastname: Hall
mesh_terms: D000553:Ambulatory Care / Q000458:organization & administration*; D015897:Comorbidity; D003299:Cooperative Behavior; D003866:Depressive Disorder / Q000628:therapy; D003924:Diabetes Mellitus, Type 2 / Q000628:therapy*; D019468:Disease Management; D006442:Glycated Hemoglobin / Q000032:analysis; D006801:Humans; D033183:Interdisciplinary Communication; D007396:Internship and Residency; D009657:North Carolina; D010348:Patient Care Team / Q000458:organization & administration*; D010349:Patient Compliance; D011320:Primary Health Care / Q000458:organization & administration*; D012017:Referral and Consultation / Q000458:organization & administration; D019037:Urban Health Services / Q000458:organization & administration*
chemical_list: D006442:Glycated Hemoglobin; C517652:hemoglobin A1c protein, human