Integrating Care Managers and Healthcare Providers 

Diabetes is a life-threatening illness affecting up to half a billion people globally, and this number is expected to increase by 51% as soon as 2045, according to the National Library of Medicine. To optimize patient care, a team-based approach integrating care managers and Federally Qualified Health Center (FQHC) providers has emerged as an effective strategy.

But what exactly is integrative care, and what does it entail? Care managers, often nurses and trained professionals such as physicians, specialists, and therapists, work collaboratively with healthcare providers to ensure that patients have access to the necessary resources and interventions, including the following:

• Appointment scheduling
• Lifestyle modifications, e.g., physical activity recommendations
• Medication management and care planning
• Ongoing support and patient education

A multidisciplinary team approach involving the diabetic patient, their primary caregiver, and additional medical experts like therapists is an excellent technique for reducing the development of diabetes-related health problems, including heart disease, blindness, kidney disease, and amputations. Let’s examine some advantages of integrating this strategy into your care plan.

Increased Access to Care

By integrating care managers and FQHC providers, the team approach ensures that patients with diabetes can access a wide range of essential services, including diagnostic testing, personalized dietary guidance, emotional and psychological support, and referrals to specialized services.

This approach addresses common barriers to treatment, such as geographical distance, financial constraints, and limited-service availability. Care managers are crucial in connecting patients to appropriate healthcare resources, arranging appointments, and coordinating the necessary care. Thus, diabetic patients, especially in underserved or low-income communities, gain greater access to comprehensive care that caters to their specific needs.

Better Coordination of Care

At the heart of the team approach lies the emphasis on better care coordination. Diabetes is among the biggest challenges in the United States healthcare system and is a complex condition that requires a holistic understanding and management strategy. By integrating care managers and healthcare providers, a seamless and comprehensive approach to patient care can be achieved. Among the medical professionals involved in integrative care include:

1. Endocrinologist

An endocrinologist is a medical specialist who focuses on the endocrine system, which includes the pancreas responsible for insulin production. Endocrinologists are vital in the team approach to diabetes care, especially for patients with complex diabetes cases or those requiring advanced treatment options. They provide specialized knowledge in diabetes management, adjust medication regimens, and offer guidance on insulin therapy and other advanced treatment modalities.

1. Registered Dietitian/Nutritionist

Nutrition plays a crucial role in diabetes management, and registered dietitians/nutritionists are integral to the diabetes care team. They provide individualized nutrition counseling, develop meal plans, and educate patients on the importance of a balanced diet in maintaining stable blood sugar levels. Registered dietitians/nutritionists also handle weight management issues and advise patients on portion control and appropriate food choices, allowing them to make informed dietary decisions.

1. Podiatrist

Foot complications such as venous ulcers are common among individuals with diabetes, making podiatrists essential members of the diabetes care team. In fact, a study by specialists in vascular biology found that diabetes mellitus was responsible for 25% to 90% of amputations in a sample group examined.

Podiatrists specialize in the diagnosis and treatment of foot-related issues. They conduct regular foot examinations, provide preventive foot care education, and address any foot complications that may arise. Podiatrists are critical in minimizing the risk of foot ulcers, infections, and amputations through early detection and comprehensive foot care management.

1. Mental Health Professional

Diabetes management can significantly impact a patient’s mental well-being, making mental health professionals invaluable in the care team. Psychologists, psychiatrists, or social workers support patients experiencing diabetes-related stress, anxiety, depression, or other mental health challenges. They offer counseling, coping strategies, and referrals to specialized mental health services when necessary, ensuring holistic care for patients.

In particular, care managers link the numerous healthcare specialists involved in a patient’s treatment process, promoting communication and the crucial exchange of information. This coordinated effort ensures that all facets of the delicate diabetes care journey are in sync and that no vital information or interventions fall through the cracks.

More Effective Treatment

A team-based approach to diabetes care transcends the boundaries of conventional treatment methods, presenting a comprehensive and personalized paradigm. This approach entails the collaborative efforts of care managers and FQHC providers, who synergistically work together to craft interventions that precisely tackle the distinctive hurdles confronted by each patient.

Considering individual needs, circumstances, and medical histories, this cohesive team can forge customized treatment plans that maximize outcomes and enhance overall health and well-being. Some of the treatment plans incorporated in integrative care include:

• Nutrition Therapy: Nutritionists recommend healthy, personalized meal plans that not only assist in blood sugar regulation but also promote the development of sustainable eating habits.
• Physical Activity Prescription: Exercise physiologists to develop tailored exercise programs based on the patient’s fitness level and extent of medical conditions
• Diabetes Self-Management Education (DSME): Certified diabetes educators deliver comprehensive education programs to empower patients in self-care management
• Diabetes Foot Care: Podiatrists or foot care specialists assess and manage foot-related complications associated with diabetes, such as neuropathy, ulcers, or infections
• Diabetes Complications Management: Specialists, such as cardiologists, nephrologists, ophthalmologists, or endocrinologists, collaborate with the primary care team to manage and prevent diabetes-related complications

Increased Patient Education

Patient education holds immense significance in diabetes care, and the inclusion of care managers amplifies educational efforts. Care managers can provide personalized educational materials, conduct one-on-one counseling sessions, and facilitate group education programs. Diabetes Self-Management Education encompasses various aspects of diabetes management, such as:

• Blood glucose monitoring
• Healthy eating habits
• Regular medical checkups
• Physical activity recommendations
• Medication and prescription management
• Mental health and stress management

Comprehensive patient education empowers patients to make well-informed choices and take control of their health by providing them with the knowledge and skills they need to manage their diabetes effectively. This education is crucial for enhancing self-care behaviors, fostering adherence to treatment plans, and preventing diabetes-related complications.

Improved Communication

Effective communication is essential to successfully managing diabetes, and a team approach facilitates this crucial element. With care managers acting as liaisons between patients and FQHC providers, there is a more seamless flow of information.

Care managers can ensure that patients’ concerns, questions, and treatment updates are relayed to the healthcare team, promoting a comprehensive understanding of the patient’s condition. This enhanced communication enables healthcare providers to make informed decisions and adjustments to the treatment plan, addressing any emerging issues promptly.

Additionally, care managers can reinforce healthcare provider recommendations, clarify instructions, and address any misconceptions or barriers patients may have, ultimately improving patient outcomes.

Cost Savings

By focusing on preventive measures, including regular screenings and patient education, the team approach aims to identify and address potential issues early on, preventing complications that could lead to costly interventions. For example, proactive monitoring of blood glucose levels, blood pressure, and cholesterol can help identify risks and enable timely intervention, potentially averting the need for hospitalizations or expensive treatments.

Furthermore, the team approach promotes efficient resource utilization by coordinating care and streamlining communication among healthcare professionals involved in diabetes management. This collaborative approach reduces duplication of tests and unnecessary procedures and eliminates fragmented care, often resulting in yearly medical expenses of $16,752 on average.

Enhancing Diabetes Care through a Preventive Team Approach

So, a team approach to diabetes care that integrates care managers and FQHC providers offers many benefits to patients with diabetes. By providing patients, especially in underserved communities, with better access to diabetes care, more effective treatments, and cost savings, a preventive care approach can help improve patients’ overall health and well-being.