TY - JOUR T1 - Multidisciplinary Team Approach to Improved Chronic Care Management for Diabetic Patients in an Urban Safety Net Ambulatory Care Clinic JF - The Journal of the American Board of Family Medicine JO - J Am Board Fam Med SP - 245 LP - 246 DO - 10.3122/jabfm.2012.02.110243 VL - 25 IS - 2 AU - Hazel Tapp AU - Shay E. Phillips AU - Dael Waxman AU - Matthew Alexander AU - Rhett Brown AU - Mary Hall Y1 - 2012/03/01 UR - http://www.jabfm.org/content/25/2/245.abstract N2 - 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. ER -