RT Journal Article
SR Electronic
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
FD American Board of Family Medicine
SP 245
OP 246
DO 10.3122/jabfm.2012.02.110243
VO 25
IS 2
A1 Hazel Tapp
A1 Shay E. Phillips
A1 Dael Waxman
A1 Matthew Alexander
A1 Rhett Brown
A1 Mary Hall
YR 2012
UL http://www.jabfm.org/content/25/2/245.abstract
AB 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.