At the heart of all patient-centered care should be a supportive team backing the patient in multiple facets. Here’s how to implement it.

Webinar Presenters: 

  • Colleen Velez: Corporation for Supportive Housing (CSH)
  • Darlene Jenkins: National Health Care for the Homeless Council
  • Jamie Carder and Barbra Barbie Forest: Health Partners of Western Ohio


In part four of the AAPCHO diabetes learning series, speakers concluded that team-based care is a valuable asset toward health clinics’ initiatives. They specifically covered diabetes management but in addition to diabetes management initiatives, team-based care should be prioritized for most health initiatives supporting the highest risk patients. Afterall, this will lower their long-term risk and reduce overall expenditures. The definitions of patient-centered and team-based care often overlap, with the overarching goal of providing the patient with valuable, supportive care tailored to them.



Nearly half of all national health care spending is spent on the top five percent of patients with the highest spending, while 20 percent of national spending goes toward the top 1 percent. These high cost patients are often routinely hospitalized and burdened with chronic diseases.¹


Expanding a care team not only lessens physician stress and improves patient experience, but a natural cost reduction follows from these benefits as well. One analysis found that optimizing care teams for patients with complex conditions can save health care organizations $1.2 million for every 10,000 patients served.2 These savings can stem from avoided hospitalizations and ED visits. For example, a Texas-based health system found that just by supplying community health workers to diabetic patients, this effort saved an average of $137 per patient by reducing inpatient encounters.²


Team-based care, therefore, adopts a patient-first mindset, thoughtful of an individual’s physical and psychosocial wellbeing. 


“[Team based care is] really, at the core, central to the patient, and providing the care around them that they need,” said Colleen Velez, from the Corporation for Supportive Housing (CSH), at the start of the webinar. “It’s something that has been integral in diabetes management and control for a long time.”


Velez gave the following definition for team-based care during the webinar, provided by the National Academy of Medicine. 


“The provision of health services to individuals, families, and/or their communities by at least two health providers who work collaboratively with patients and their caregivers- to the extent preferred by each patient – to accomplish shared goals within and across settings to achieve coordinated, high-quality care.”


Components of a Diabetes Care-Team

To form a well-equipped care team, Velez recommends thinking of the situation as a circle, surrounded by two rings. In the circle, is the patient. All decision making should revolve around their best interests and be considerate of them as an individual. In the inner ring, should be clinicians dealing with the diabetes and the principal corresponding health issues. These clinicians should include: 


  • A primary care provider
  • A registered nurse
  • A dentist
  • A podiatrist


In the outer ring, should be organizations and persons that provide social support services. Without a holistic approach to care, some patients with diabetes may not truly be able to focus on a care plan, especially if they don’t have the means to carry it out. The outer ring should include:  


  • Case manager
  • Support groups
  • Behavioral Health Services
  • Transportation services


By doing so, diabetic care can happen on a continuum.

Barriers that impede effective self-management can include social determinants of health (SDOH). See at the end of our blog some of our other articles giving step on what actions to take, beyond recognition, to best integrate a patient’s surroundings and identity into their care plan.


The Why and How of Team-Based Care

Darlene Jenkins from the National Health Care for the Homeless Council said team-based care should be appreciated and used for its multitude of benefits. 


“It is an evidence based practice,” Jenkins said. “When you have the integration of  a team, it does improve patient experience, but also the provider relationships with patients”


She said it has also been shown to decrease A1c levels and improve patient outcomes


Care coordination can be divided into internal and external efforts. Components of internal care coordination include: 


  • Ability to share data
  • Defined team structure, roles and responsibilities
  • Coordinated care planning
  • Strong partnerships
  • Trauma informed care
  • Harm reduction approach
    • Note: This technique is not just for substance abuse. For example, if a patient with diabetes is drinking 2 liters of soda a day, a clinician may ask them to drink only one liter or substitute with a flavored water. 


Telehealth, Jenkins said, comprises a large part of external coordination. The patient has access to all their providers, to whom they are able to ask questions and connect with routinely. This also allows a patient to reach and have appointments with all their providers at a central access point, which decreases any stress associated with in-person appointments. 


“We know that [telehealth] is a way to provide care for diabetes management,” Jenkins said. 


Coming Together

Jamie Carder and Barbra Barbie Forest from Health Partners of Western Ohio elaborated on their clinic’s success using team-based care, as well as highlighted the importance to convene regularly to make it all work. This could mean hosting monthly meetings to make sure all specialities are on the same page regarding patients. But it could also mean just having time to bond and connect as a staff to strengthen the working relationship, as well as having a space to vent and troubleshoot any frustrations. 


How We Can Help

Certintell’s care model thrives on the concept of team-based care. We work with your clinic’s providers to connect your patient’s through specialty physicians, health coaches and medical interpreters to ensure your patients are receiving well-rounded care. We look to be an extension of your health center, a helping hand to help connect all the dots. 



¹ “Redesigning Care for High-Cost, High-Risk Patients.” Harvard Business Review, 7 Feb. 2017,


² “How Broader Primary Care Teams Can Decrease Healthcare Costs.” RevCycleIntelligence, 25 Oct. 2016,