Care coordination is a model health system that ensures more efficient patient care by delivering services across different providers, from healthcare providers to social services. It focuses on the diminishing influence of social factors on patients’ outcomes by systematically providing them with resources and support (Albertson et al., 2021). Research highlights that care coordination results from intentional and unified efforts to better plan and deliver patient care, communicate and share information, and assure continuity of services across the healthcare and social service sectors. The assessment reported the mainly structured patient needs assessment, personal contact with patients, and standardized care coordination protocols.
Chronic diseases such as Type 2 diabetes are now being recognized as the major threats confronting the world that require people and their health systems to deal with. Indeed, the management of Type 2 Diabetes entails many interventions, including not only medical but also lifestyle changes, constant support, and cooperation between healthcare providers. The collaborative care approach is well suited by Richardson et al. (2021) when they highlight the necessity of collectivist care, offering the best outcomes for patients with Type 2 Diabetes as well as the cost-effectiveness of the healthcare system.
The integration care and coordination combination has been widely adopted as T2 diabetes keeps revealing more significantly tailored models for their management. These models’ purpose is to overcome the difficulties of the traditional healthcare system that often relies on the individuals’ actions and does not coordinate the efforts of the medical staff to the full. Not only that, but these models also bring to the fore the idea that an illness has to be managed as a chain, including the patient, with the patient at the center of it all. The outlined treatment plan must be weighed against the patient’s needs, priorities, and life purpose.
Patient G J, an African-American aged 55 years, is a male diagnosed with Type 2 Diabetes. His glucose level could be better managed despite adhering to the oral medications. His current treatment plan includes metformin treatment, dietary changes, physical exercise 3 times a day for 30 minutes, and regular checkups of the blood glucose levels and HbA1c.
Description of the Family Practice Clinic: The patient attends a community-based clinic. The family practice clinic offering, catering to a varied clientele, has three primary care physicians, two nurse practitioners, three registered nurses, and administrative staff. Under this scenario, patients usually visit the facility with reported chronic conditions, such as diabetes, hypertension, hyperlipidemia, and asthma, which are the current public health issues.
In the suggested model, primary care providers work with nurse educators, registered dietitians, and community health workers to ensure the availability of comprehensive care for patients with Type 2 Diabetes. Primary care physicians oversee patient care, while nurse educators personalize educational and medication administration counseling. Ansari et al. (2021) argue that the chronic care model (CCM) was developed as a framework for the health and health interventions system to provide solutions for individual and population health outcomes. It focuses on the patients and all the professionals that come in contact with them and integrates teamwork.
The benefits of the Care Coordination Model are that the developed site allows patients to get more holistic treatment, expands patient education, and enhances social support, eventually leading to improved health outcomes and decreased healthcare use. Integrated care forms provide practical components for diabetes management, leading to improved glycemic control, reduced hospitalizations, and improved patient life satisfaction. According to Albertson et al. (2021), their review includes 25 studies of 19 care coordination programs that managed patients’ social service and health needs. The services included training and teaching essential skills. The model highlights nine hypothesized core factors that appeared in most successful programs and found that high-frequency communication, systematic patient needs assessment, and documented protocols were the most commonly used in the programs.
When the fit within the Clinic Setting is taken into, the model aligns with the clinic’s vision to deliver patient-centered care and help patients with chronic conditions manage their conditions. Staff training in diabetes management and communication skills is essential enough to be considered an integral part of the implementation process (Hempel et al., 2023). What needs change in the clinic are workflow modifications and technology solutions to help with the smooth cooperation of the team members, which ensures efficiency and a high level of patient satisfaction.
A type 2 diabetes management model based on integrative and coordinated care is one of the most promising models for a family practice setting. The model is centered on leveraging knowledge from multiple fields and patient-orientated approaches to improve outcomes and enrich the quality of life for those with diabetes. Research and practice need to look at how care coordination models are evaluated and explore new strategies for coping with the complications of patient needs.
Albertson, E. M., Chuang, E., O’Masta, B., Miake-Lye, I., Haley, L. A., & Pourat, N. (2021). A systematic review of care coordination interventions linking health and social services for high-utilizing patient populations. Population Health Management, 25(1), 73–85. https://doi.org/10.1089/pop.2021.0057
Ansari, R. M., Harris, M. F., Hosseinzadeh, H., & Zwar, N. (2021).Applications of a chronic care model for self-management of type 2 diabetes: a qualitative analysis. International Journal of Environmental Research and Public Health, 18(20), 10840. https://doi.org/10.3390/ijerph182010840
Hempel, S., Ganz, D., Saluja, S., Bolshakova, M., Kim, T., Turvey, C., Cordasco, K., Basu, A., Page, T., Mahmood, R., Motala, A., Barnard, J., Wong, M., Fu, N., & Miake-Lye, I. M. (2023). Care coordination across healthcare systems: development of a research agenda, implications for practice, and recommendations for policy based on a modified Delphi panel. BMJ Open, 13(5), e060232. https://doi.org/10.1136/bmjopen-2021-060232
Lockhart, E., Hawker, G. A., Ivers, N. M., O’Brien, T., Mukerji, G., Pariser, P., Stanaitis, I., Pus, L., & Baker, G. R. (2019). Engaging primary care physicians in care coordination for patients with complex medical conditions. Canadian Family Physician, 65(4), e155–e162. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6467654/
Richardson, C. R., Borgeson, J. R., Van Harrison, R., Wyckoff, J. A., Yoo, A. S., Aikens, J. E., Griauzde, D. H., Tincopa, M. A., Van Harrison, R., Proudlock, A. L., & Rew, K. T. (2021). Management of Type 2 Diabetes Mellitus. In PubMed. Michigan Medicine University of Michigan. https://www.ncbi.nlm.nih.gov/books/NBK579413