Healthcare Redefined Around You

Long-term coordinated care for diabetes

woman standing with doctors and nurses

It’s always good to be part of a team, especially when it comes to your healthcare. If you have a chronic condition like diabetes, team care can be critical to your long-term health.

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If your primary care physician practices in a patient-centered medical home, your team is already in place.

What is a patient-centered medical home?

A patient-centered medical home isn’t a place, but a method of care delivery. It’s led by your primary care doctor, and includes nurses, care coordinators, physician assistants and nutritionists.

The team works to tailor your care to you, taking into account your general health, age, medication needs and other factors.

Long-term coordinated care for chronic diseases

“The specific role is aimed at helping to care for patients at high risk for developing long-term complications of chronic diseases like diabetes,” says Kevin Hopkins, MD, a family physician at Strongsville Family Health Center, a recognized patient-centered medical home.

“Instead of care being fragmented and episodic, it’s continuous and longitudinal,” says Dr. Hopkins.

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Your care is designed not just to get you well, but to keep you that way.

For example, if you’re ever hospitalized, your team contacts you within one or two days after your discharge to make sure you’re OK — and keeps checking every week for four weeks. They’ll also help you navigate through the system for any follow-up care you need.

How team care can help you control your diabetes

For patients with a condition like diabetes, coordinated, ongoing care is crucial.

If you have just been diagnosed with diabetes, you may be put in touch with an endocrinologist and diabetes specialists, who become yet another part of your healthcare team.

Your team can help you to:

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  • Establish a routine to check your blood sugar levels
  • Maintain a healthy diet
  • Get on an exercise program
  • Keep your blood pressure and cholesterol under control
  • Check in with you to make sure you’re monitoring your blood sugars and they are at safe levels

Says Dr. Hopkins, “If there’s a problem, they can make medication readjustments on the fly, too. The main goal is to avoid complications of the disease.”

“Instead of waiting for people to contact us, we reach out to them to keep them healthy,” he adds. “It’s common sense.”

Cleveland Clinic’s Medicine Institute was officially recognized as a patient-centered medical home in 2010. Medical homes exist at the Family Health Centers and on Cleveland Clinic main campus. Different models of team-based care are being piloted at three of Cleveland Clinic’s primary care locations: Strongsville, Independence and Main Campus Internal Medicine.

Related posts

Your ‘Home’ Team for Your Healthcare  
What is Personalized Healthcare?

More  information  

Diabetes Basics  
Free Diabetes Treatment Guide

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