Team Based Care

Overview

Team-based care improves the management of chronic disease by leveraging the expertise of multiple healthcare professionals. Coordinated care supports better patient outcomes, medication adherence, preventive care, and self-management.

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‍_{Resource: See Team-Based Resources (References 1-3)}

‍Key Members of the Care Team

• Primary Care Provider
  
  • Diagnosis, treatment planning, risk assessment, care coordination, early
• Nurse
  
  • Patient education, monitoring, outreach, self-management support
• Pharmacist
  
  • Medication monitoring, adherence support, and optimization
• Registered Dietitian
  
  • Nutrition counseling, individualized dietary strategies
• Diabetes Care & Education Specialist
  
  • DSMES, behavior change support
• Community Health Worker
  
  • Connect patients with resources and address social needs
• Social worker
  
  • Assessment of social determinants of health and connect to resources
• Specialists
  
  • Endocrinology, nephrology, cardiology, etc.

_{Source: See Team-Based Resources (References 6-9, 11)}

‍Care Team Coordinator (CTC):

A designated team member who supports care coordination by documenting treatment plans, facilitating communication across providers, assessing patient needs, and ensuring care is tailored to each patient. The CTC helps advocate for patients, supports shared decision-making, and ensures the patient’s goals and preferences remain central to their care.

Team Collaboration as a Strategy to Reduce Clinician Burnout

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Learn More

• Team-Based Care Tool
• Embedding Pharmacists Into the Practice | Patient Care | AMA STEPS Forward | AMA Ed Hub
• Sharing Open Notes With Patients

_{Source: See Team-Based Resources (References 5, 10)}‍