Type 2 diabetes is a multifaceted condition that requires ongoing attention and effort from both patients, physicians and care teams to manage effectively. Evidence shows that the chances of long-term success in treating and preventing type 2 diabetes when physician practices employ the team-based care approach.
A newly revamped AMA STEPS Forward® toolkit, “Team-Based Care of Type 2 Diabetes and Prediabetes,” can improve physicians’ capacity to help patients reach their glycemic goals through such an approach. The toolkit also pinpoints opportunities to improve the health of patients with prediabetes and diabetes while saving time for the care team.
Physicians and other health professionals can follow these eight steps outlined in the toolkit to develop an efficient team-based approach to managing type 2 diabetes and prediabetes.
Engage your team
That means including front-desk staff, medical assistants and other care-team members in meetings early on so that everyone is on the same page and understands the importance of improving how type 2 diabetes and prediabetes are managed in the practice. When a team is invested in the process and knows the practice or health system values their input, its members are more willing to help lead change.
Medical assistants should also be involved in diabetes education through a professional development program. This will help medical assistants answer questions about diabetes-related laboratory tests ordered as part of previsit lab testing, during rooming or discharge processes or when a patient receives their visit summary or results through the patient portal.
Assess impact of poor glycemic control
Start by discussing the overarching impact of poor glycemic control among patients with type 2 diabetes in the clinic and then ask each team member to identify the negative consequences of poor glycemic control—such as delays in the schedule because of prolonged visits. Physicians should also ask team members to identify the benefits of improving control.
Then get granular and analyze practice data to determine how many patients have type 2 diabetes or prediabetes. Start with the patient-care registry or a report from your IT or billing team.
Pick a type 2 diabetes focus
“Patients with diabetes often have comorbid conditions and psychosocial factors that impair their ability to achieve and maintain optimal glycemic levels,” the toolkit says. “To ensure that the care team does not become overwhelmed, steer them toward a small, targeted initiative that will likely succeed.”
For example, identify one area for each team member to focus on in caring for patients with diabetes such as screening for depression, medication adherence or implementing standing orders.
Getting started with prediabetes
More than one in three adults in the U.S. have prediabetes. To that end, the U.S. Preventive Services Task Force recommends screening for prediabetes and type 2 diabetes in adults 35–70 years old with overweight or obesity. Physicians and care teams play an integral role here too. But it can be a lot at once, so consider starting with one process. For example, the practice can focus on identifying more at-risk patients with a prediabetes screening program.
Learn more by watching the AMA STEPS Forward webinar, “A Team Based Approach to Treating Prediabetes.”
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Pilot an intervention with your team
Once the team has chosen something to focus on, create a plan-do-study-act cycle to perform small tests on specific changes for quality-improvement purposes. Post a tick chart on the wall where staff can see the progress. For example, one project goal may be increasing the percentage of patients referred for diabetes education. To meet that goal, create a standing order for diabetes education referral.
Support patients with education
“Education is paramount for all patients with prediabetes or type 2 diabetes. Patients must understand how to monitor and manage their condition at home to reach their glycemic goals and avoid preventable complications,” notes the toolkit. To start, help patients understand their numbers and provide lifestyle education. If a patient has prediabetes, the education should be used as a supplement to their participation in a National Diabetes Prevention Program lifestyle program.
The AMA’s Diabetes Prevention Guide supports physicians and health care organizations in defining and implementing evidence-based diabetes prevention strategies. This comprehensive and customized approach helps clinical practices and health care organizations identify patients with prediabetes and manage their risk of developing type 2 diabetes, including referring patients at risk to a National Diabetes Prevention Program lifestyle-change program based on their individual needs.
Use shared decision-making
Patients are more likely to stick to the plan if they helped design it. Have shared decision-making conversations, ask patients to repeat back what you’ve discussed, ask “what questions do you have for me” and provide education tools for patients and their families to review at home.
Screen for social drivers of health
Social drivers of health factors impact the prevention and management of type 2 diabetes. For example, food insecurity and low diet quality are associated with suboptimal glycemic control, says the toolkit. By adding screening for social drivers of health, it can help physicians and their teams improve population health in their practice.
Learn more by watching this AMA STEPS Forward Innovation Academy webinar about prediabetes quality measures.
Also listen to an “AMA STEPS Forward Podcast” about expanded Medicare coverage for screening tests for type 2 diabetes and prediabetes prevention.
AMA STEPS Forward open-access toolkits offer innovative strategies that allow physicians and their staff to thrive in the new health care environment. These resources can help you prevent burnout, create the organizational foundation for joy in medicine and improve practice efficiency.
