Frequently Asked Questions

Team Based Care Calculator


This Team Based Care Calculator (Team Calculator) is based on the principles as detailed in the latest (2018) Diabetes Canada Clinical Practice Guidelines (Clement et al., 2018). An explanation of the Chronic Care Model (CCM) and the Components of the CCM can be found in summary format on page S29.


  1. Where do I find my input data?
  2. There are 2 possible sources of this information:
    1. From your patient panel data extracted from your EHR. This can be used as a number or a .csv file can be imported into the tool.
    2. If you have signed up with the Health Data Coalition (HDC), the information will be on your dashboard.

    The best way to ensure your data is reliable is to, with the assistance of PSP, clean up your EHR patient panel and sign up with the HDC.

  3. My one-on-one management of diabetes is comprehensive. A team-based approach will not make a difference, right?
  4. Wrong, it will make a difference.

    Research(Litaker D et al., 2003) results indicate that even the addition of only a nurse to the management team will improve both process and outcome measures.

    It appears that the most basic team to improve the quality of chronic disease management (CDM) will be a physician, medical office assistant (MOA) and nurse. Without those 3 team members it will not be possible to cover all the components of the chronic care model(Clement et al., 2018).

  5. How do I accommodate all these team members in my clinic? There is no room.
  6. You do not need to. You already have a medical office assistant (MOA) working with you. You may only need to add the nurse to your on-site team in your clinic (Patient Medical Home/PMH). The PMH team will therefore consist of the MOA, nurse and you.

    The other health professionals (exercise expert, dietitian, clinical pharmacist and social worker) can be off-site, providing services to a few PMHs within a PMH network.

  7. Who will pay for this comprehensive, team-based approach?
  8. Great question.

    The purpose of this tool is to give you an idea what is required to provide comprehensive, team-based, CCM, evidence-based diabetes care. This approach will improve measures as listed later.

    It is outside the scope of this project to address funding options. Hopefully this tool will provide you with information to approach funding authorities for consideration.

    The success of similar models has been tested in a ‘general practice network’ setting. This study(Hull, Chowdhury, Mathur, & Robson, 2014) also notes that the investment will achieve ‘clinically important improvements in diabetes care’.

    A Canadian study(Rosella et al., 2016) looked at the impact of diabetes on healthcare costs and showed that >50% of the cost of diabetes care occur through acute inpatient hospitalizations (treating complications). Looking at cost over an 8-year period it was found that the average per person healthcare spending for diabetes care was more than twice (C$16,000) that of non-diabetes controls (C$6,000). A similar study(Bruno et al., 2012) done in Italy showed a 4-fold higher cost in diabetes patients. Funding authorities should be highly motivated to fund strategies to reduce the cost of managing complications. You have an opportunity to advocate on behalf of diabetes patients.

    If you want to get an international perspective on different funding models of care, then this Australian publication is a great source (Donato & Segal, 2010).

  9. Communication within a team can be complicated. How do I ensure we share the same information?
  10. This is a very important question. Your team will need a communication strategy. The Practice Support Program (PSP) has a small group learning session with a focus on developing team communication strategies.

    But, by sharing the same EHR you will have access to the same information. You can also as a team design your own templates for record keeping simplifying the process.

  11. The time commitment by the nurse seems very high. Why?
  12. Currently you have a MOA as the administrative quarterback of your chronic disease management projects. You are burdened with all clinical decisions, communications and actions.

    The nurse in this program becomes your clinical quarterback. He/she will lessen your clinical load by communicating with patients by phone and in person providing answers to questions (if available). The nurse will also assist in setting realistic goals for patients, promoting patient self-management/empowerment.

    Feedback from participants in the GAP diabetes study(Khan et al., 2015) (unpublished) indicate that a telephone interview with emphasis on goal-setting based on expert advice shared during the previous session, would greatly enhance lifestyle modifications. Success of an education program does not necessarily translate into lifestyle changes and improvements in outcomes.

    Some of the functions of the nurse as clinical quarterback have been described in some studies(Loskutova et al., 2016) as ‘patient navigators’. These navigators function mainly through telephone interviews with patients. These programs have been shown to be successful in promoting lifestyle changes.

  13. It seems a duplication to have two team members (one being the nurse) involved in every in-person consultation. What is the value of that?
  14. Even though patients will appreciate a team-based approach, there is a risk that they can be confused if they do not receive a consistent message. The nurse, by attending all sessions, will be able to ensure that messages are clearly understood. He/she will also be able to communicate to team members if there are conflicting messages shared with patients.

    In addition, it will provide a cross-education effect to ensure the nurse (as clinical quarterback) will have a solid baseline knowledge of the whole program.

    The nurse is responsible for the personalized goal-setting part of the program through motivational interviewing. The goals are based on the information shared during a preceding consultation. It is therefore essential for the nurse to have a detailed knowledge of the information shared.

    The ‘telephone contact’ provides an opportunity to assess whether the content of the previous session was clearly understood and assist with goal-setting, ensuring they are S.M.A.R.T. (specific, measurable/outcome-focused, attainable, relevant and within a realistic timeline)

  15. What is my role as physician?
  16. You are the primary care specialist, team-lead and supervisor of the CDM program.

    While team members have a focus on specific interventions to improve outcomes, you look at the total picture, comparing measures with goals. You make decisions on referrals to other health professionals (cardiologist, nephrologist, vascular surgeon, ophthalmologist, etc.).

    You also oversee the quality improvement (QI) component of the program.

    While doing all the above you remain a clinician and do not become simply a ‘manager’.

  17. What is the role of the medical office assistant?
  18. The MOA is the administrative quarterback of the CDM program.

    This involves enrollment of patients into the program, making appointments, ensuring results are available, preparing educational material, ensuring follow-up is arranged and investigations are done as planned.

    The MOA can also assume the role of the QI coordinator of the program, assisting the physician. Training for this role is provided by Practice Support Program through the QI small group learning sessions.

    The MOA is also the first point of contact for patients in the program and will direct questions to other team members as appropriate. It is therefore essential for the MOA to be aware of the roles of all team members.

  19. I think the role of the clinical pharmacist can overlap with my role. Can that cause conflict?
  20. It should not if roles are clearly defined.

    The clinical pharmacist will explain the actions and potential side-effects of medication with patients in detail. As a physician you often do not have the time to do this to the same extend.

    In addition, clinical pharmacists can also suggest alternative medications if patients cannot afford certain medications. Patients can then address this at their next visit with the physician. Pharmacists can also share funding options with patients.

    Improvement in comprehensive chronic disease management with the introduction of a clinical pharmacist has been well established(Dunn et al., 2015).

    There is also evidence(Deters et al., 2018) that community-based pharmacist-led interdisciplinary teams can improve diabetes outcomes. This emphasises the potential contribution of these health professionals to the diabetes management team.

  21. I understand the contributions of the exercise expert and the dietitian. Is the contribution of a social worker necessary?
  22. Yes. Social determinants of health should be considered in all patients, especially patients with chronic disease. These patients are at a high risk of social isolation and information about community-based programs can be shared by the social worker.

    Social workers will also consider the financial burden of chronic disease and make recommendations.

    Research(Walker, Gebregziabher, Martin-Harris, & Egede, 2014) indicate an association between psychosocial factors and glycemic control in patients with diabetes as an independent risk factor. Comprehensive care should therefore consider these factors.

    Social workers can document and consider quality of life measures, anxiety/depression symptoms and confidence in patient self-management.

    A study(Calderon-Margalit et al., 2018) done is Israel 4 years after the introduction of a comprehensive national program for diabetes management found that the gap in outcomes between Israeli Jews and Arabs narrowed. Recognizing social diversity in CDM programs should therefore be considered, because it will likely effect outcomes.

    Improved outcomes through the involvement of a dietitian have been well established(Marincic et al., 2017).

    The same applies to benefits of exercise prescription(Mendes, Sousa, Reis, & Themudo-Barata, 2017) in diabetes management.

  23. Why is a second year of ‘active maintenance’ required in these patients? Surely, an intensive 1-year investment should be enough?
  24. Research(Litaker D et al., 2003) indicate that even with an intensive 1-year intervention, if there is limited investment in maintenance, some outcomes will return to the pre-intervention levels by 1 year after the intervention.

    Unpublished data from the GAP study(Khan et al., 2015) confirmed the same.

    There is also evidence that frequency of contact with the diabetes management team over a 2-year period improved glycemic control when compared with fewer contacts with the team(BeLue, Figaro, Peterson, Wilds, & William, 2014).

  25. How will I know this comprehensive diabetes management plan is successful?
  26. Physicians, staff and patients should be happier. After an initial investment, funding authorities should also be happier.

    Some of the measures will be quantitative, but qualitative measures should also be considered.

    The following quantitative measures should be considered in the QI process:
    1. Process measures
    2. Outcome measures
    3. Balance measures
    Process measures
    • Quality of comprehensive care documentation
    • Enrollment
    • Adherence
    • Weight/BMI/waist circumference
    • A1C (Often incorrectly seen as an outcome measure. It is a surrogate marker)
    • Triglyceride/HDL ratio
    • Kidney function documentation
    • Blood pressure
    • Annual eye examination documentation
    • Healthy eating (3-day recall)
    • Physical activity levels
    • Vaccinations
    Outcome measures
    • Quality of life
    • Diabetes literacy
    • Self-management
    • Number of diabetes medications
    • Diabetes complications: Non-fatal CVD, CVD deaths, microvascular complications, macrovascular complications. Of interest is that an Israeli study(Calderon-Margalit et al., 2018) observed changes in complications (including hospital visits) over a 10-year period. This emphasizes the fact that some outcome measures can change over a short period of time, but others can take much longer to show significant change. This should be kept in mind when considering ‘return on investment’ in comprehensive chronic disease programs. Other studies showed improvements after early comprehensive interventions in all-cause mortality after 5 years(Davis, Chubb, Bruce, & Davis, 2016). A model (the Markov model) which uses evidence from available studies and simulates the natural history of diabetes, predicts that out of 1000 patients, 123 would avoid complications over 13 years(Chao et al., 2014) if they receive comprehensive care.
    Balance measures
    • Provider satisfaction
    • Staff satisfaction
    • Income/cost of program: Even though there is a significant increase in initial cost(Eastman et al., 1997), it is partially offset by reductions in the cost of managing complications.