New Initiatives and Programs in Diabetes Management to Improve Patient Care: FAHP 2010 Annual Conference September 21,

1. New Initiatives and Programs in Diabetes Management to Improve Patient Care:FAHP 2010 Annual ConferenceSeptember 21, 2010 Jose M. Cabral, MD, FACE Chair, Department of Endocrinology cabralj@ccf.org

2. Diabetes is a growing problemPrevalence All Ages, 2007 23.6 million people have diabetes (7.8% of the total US population) Of these 5.7 million are undiagnosed 57 million American adults have impaired fasting glucose 48.3 million diagnosed cases are anticipated by 2050. 23.6 million people have diabetes. Of these 17.9 are diagnosed, and 5.7 million are undiagnosed. Of the diagnosed population � type 1 accounts for 5 to 10 percent or about 895,000 � 1, 790,000 people. Type 2 accounts for 90 to 95% or about 1,611,000 to 1,700,500cases, Reference National Institute of Diabetes and Digestive and Kidney Diseases. National Diabetes Statistics, 2007. Bethesda, MD: U.S. Department of Health and Human Services, National Institutes of Health, 2008. 23.6 million people have diabetes. Of these 17.9 are diagnosed, and 5.7 million are undiagnosed. Of the diagnosed population � type 1 accounts for 5 to 10 percent or about 895,000 � 1, 790,000 people. Type 2 accounts for 90 to 95% or about 1,611,000 to 1,700,500cases, Reference National Institute of Diabetes and Digestive and Kidney Diseases. National Diabetes Statistics, 2007. Bethesda, MD: U.S. Department of Health and Human Services, National Institutes of Health, 2008.

3. Predicted Increases in the Prevalence

4. The Good News���. More therapeutic options Safer drugs Improved glucose monitoring devices Insulin pumps Artificial pancreas

5. Discovery of Insulin

6. Major discussion point: The hormonal management of diabetes is less than a century old, with the first use of insulin in 1922 and the discovery of glucagon in 1923. It was not until the 1980s that glucagon-like peptide 1 (GLP-1) and amylin were identified. Major discussion point: The hormonal management of diabetes is less than a century old, with the first use of insulin in 1922 and the discovery of glucagon in 1923. It was not until the 1980s that glucagon-like peptide 1 (GLP-1) and amylin were identified.

7. Antihyperglycemic Agents for Type 2 Diabetes Class Agents Sulfonyureas (SU) Glyburide, glipizide, glimepiride Meglitinides (Glinide) Repaglinide, Nateglinide Metformin (MET) Metformin a-Glucosidase inhibitor (AGI) Acarbose, Miglitol Glitazone (TZD) Pioglitazone, Rosiglitazone Incretin mimetics (GLP-1) Exenatide (Byetta) Liraglutide (Victoza) DPP-4 inhibitors (DPP4) Sitagliptin (Januvia) Saxagliptin (Onglyza) Amylin analogs Pramlintide (Amylin)

8. Good Glycemic Control (Lower HbA1c) Reduces Incidence of Complications

9. Type 1 DM: Intensive Insulin Therapy Decreases Microvascular Complications

10. Pen Delivery of Insulin Analogs Encourages multiple daily injections Convenient Enhances flexibility in schedule May improve accuracy of dosing (Review Bullet Points)(Review Bullet Points)

12. Continuous Monitoring Systems

13. In the upper graphic display dated October 3rd thru October 9th, one sees the patient�s daily sensor tracings during this one-week period, over-layed with the horizontal axis being time of day, and the vertical axis being glucose value. One can see the patient�s tendency to have high glucose values through the night on 5 out of 7 tracings, suggesting he needs more basal from 12am to at least 4am and maybe 8am. Glucose values in the morning hours are very labile till 12pm, then appear relatively stable, though above target, the rest of the day. There is minimal to no hypoglycemia seen in these tracings. The lower figure is the daily sensor overlay by meal report and shows the overlay of sensor readings at each meal period. One can easily see the patient needs more insulin at both breakfast and lunch, requiring a change in his current carbohydrate to insulin ratio from 1 unit to 10 grams to 1 unit to 8 grams. He has minimal glycemic excursion post- supper confirming 1 to 10 grams is fine at this meal. From the data table which is not shown, his overall sensor glucose average was 162 mg/dL, explaining why his A1C was > 7%. The above changes were made in his Bolus Wizard� calculator and basal settings. INSERT SUPERS: On Sensor Daily Overlay between 0:00 and 8:00a, in the area of white from 0 to red line bottom of graph, add words: �High Glucose Values Overnight� On Breakfast Graph and on Lunch Graph in white area from 0 to 100, add words: �Change carb/insulin ratio: 1U/8gm� In area (blue) after title Sensor Overlay by Meal, add words: �Overall sensor glucose avg. 162 mg/dL; A1C >7%� In the upper graphic display dated October 3rd thru October 9th, one sees the patient�s daily sensor tracings during this one-week period, over-layed with the horizontal axis being time of day, and the vertical axis being glucose value. One can see the patient�s tendency to have high glucose values through the night on 5 out of 7 tracings, suggesting he needs more basal from 12am to at least 4am and maybe 8am. Glucose values in the morning hours are very labile till 12pm, then appear relatively stable, though above target, the rest of the day. There is minimal to no hypoglycemia seen in these tracings. The lower figure is the daily sensor overlay by meal report and shows the overlay of sensor readings at each meal period. One can easily see the patient needs more insulin at both breakfast and lunch, requiring a change in his current carbohydrate to insulin ratio from 1 unit to 10 grams to 1 unit to 8 grams. He has minimal glycemic excursion post- supper confirming 1 to 10 grams is fine at this meal. From the data table which is not shown, his overall sensor glucose average was 162 mg/dL, explaining why his A1C was > 7%. The above changes were made in his Bolus Wizard� calculator and basal settings. INSERT SUPERS: On Sensor Daily Overlay between 0:00 and 8:00a, in the area of white from 0 to red line bottom of graph, add words: �High Glucose Values Overnight� On Breakfast Graph and on Lunch Graph in white area from 0 to 100, add words: �Change carb/insulin ratio: 1U/8gm� In area (blue) after title Sensor Overlay by Meal, add words: �Overall sensor glucose avg. 162 mg/dL; A1C >7%�

14. The Bad News�.

16. Greater Than 50% of Patients With Diabetes Need Additional Lowering of Cardiovascular Risk Factors Key Message: According to NHANES, among patients with diabetes, less than half meet individual goals for cholesterol, blood pressure, and glucose, and fewer than 10% meet all 3 goals. Supporting/Background Information Data from the National Health and Nutrition Examination Survey (NHANES) indicate that the majority of patients with diabetes have A1C, blood pressure, and total cholesterol levels that exceed treatment goals set by the American Diabetes Association (ADA) and the Third National Cholesterol Education Program Adult Treatment Panel (NCEP ATP III). The slide shows a comparison between the NHANES cross-sectional surveys conducted in 1988-1994 (NHANES III) and 1999-2000, which involved adults =20 years old with a diagnosis of diabetes. Data shown are for 1204 individuals from NHANES III and 370 from NHANES 1999-2000 for whom information on all 3 risk factors was available. Between the 2 surveys, the proportion of patients with diabetes meeting a blood pressure goal of <130/80 mm Hg and a total cholesterol goal of <200 mg/dL increased to 36% and 48%, respectively. Meanwhile, the proportion of patients meeting a glucose target of A1C <7.0% declined to 37%, despite the availability of a larger number of glucose-control agents. Of the differences in the survey results, only the increase in patients meeting cholesterol goals was statistically significant (P <0.001). The proportion of patients meeting all 3 goals remained very small between surveys, increasing from 5.0% to 7.0%. Reference Saydah SH, Fradkin J, Cowie CC. Poor control of risk factors for vascular disease among adults with previously diagnosed diabetes. JAMA. 2004;291:335-342.Key Message: According to NHANES, among patients with diabetes, less than half meet individual goals for cholesterol, blood pressure, and glucose, and fewer than 10% meet all 3 goals. Supporting/Background Information Data from the National Health and Nutrition Examination Survey (NHANES) indicate that the majority of patients with diabetes have A1C, blood pressure, and total cholesterol levels that exceed treatment goals set by the American Diabetes Association (ADA) and the Third National Cholesterol Education Program Adult Treatment Panel (NCEP ATP III). The slide shows a comparison between the NHANES cross-sectional surveys conducted in 1988-1994 (NHANES III) and 1999-2000, which involved adults =20 years old with a diagnosis of diabetes. Data shown are for 1204 individuals from NHANES III and 370 from NHANES 1999-2000 for whom information on all 3 risk factors was available. Between the 2 surveys, the proportion of patients with diabetes meeting a blood pressure goal of <130/80 mm Hg and a total cholesterol goal of <200 mg/dL increased to 36% and 48%, respectively. Meanwhile, the proportion of patients meeting a glucose target of A1C <7.0% declined to 37%, despite the availability of a larger number of glucose-control agents. Of the differences in the survey results, only the increase in patients meeting cholesterol goals was statistically significant (P <0.001). The proportion of patients meeting all 3 goals remained very small between surveys, increasing from 5.0% to 7.0%. Reference Saydah SH, Fradkin J, Cowie CC. Poor control of risk factors for vascular disease among adults with previously diagnosed diabetes. JAMA. 2004;291:335-342.

17. Treatment Inertia is a Major Reason for Poor Patient Response to Therapy :Patients Remain On Monotherapy >1 Year After First A1C >8.0%*

18. Better Diabetes Control in Clinical Trials Medication is free (no �donut hole�) Access to a team. Education Follow a protocol Titration of therapy within a time frame

19. Florida: Diabetes & Endocrinology Total Population: 16,318,656 (2002) Diabetes: ~ 1,000,000 (2002) Endocrinologists: 232 (members of AACE) 1 Endo: 70,340 population 1 Endo: 4,310 adult diabetics Average waiting time for new Endocrinology outpatient consultation in S. Fla.: ~ 3 mo.

20. Barriers to achieving good glycemic control The Global Partnership acknowledges there are barriers that need to be addressed in order for individuals to achieve glycemic goals. The Global Partnership has identified several key areas that will help the diabetes care team to increase the proportion of individuals achieving good glycemic control and thus decrease the risk of complications. These include the need for shared understanding and mutual agreement between the team members and the individual with diabetes and between each of the team members.The Global Partnership acknowledges there are barriers that need to be addressed in order for individuals to achieve glycemic goals. The Global Partnership has identified several key areas that will help the diabetes care team to increase the proportion of individuals achieving good glycemic control and thus decrease the risk of complications. These include the need for shared understanding and mutual agreement between the team members and the individual with diabetes and between each of the team members.

21. Cleveland Clinic Florida: Diabetes & Endocrinology Cleveland Clinic Florida is a not-for-profit, multi-specialty, academic, fully integrated medical center, staff model, salaried. More than 170 physicians representing 35 medical specialties and subspecialties.

22. Cleveland Clinic Florida: Multidisciplinary Diabetes Team Outpatient Diabetes Team: Members 5 Endocrinologists 1 Nurse Practitioner Nurse Educator (RN,CDE) Dietician (RD, CDE) Diabetes educators work closely with the staff endocrinologists. Office-based ADA-certified diabetes self-management education Inpatient Diabetes Team: Members Nurse Practitioner Pharmacist, CDE Endocrinologist

23. Cleveland Clinic Florida: Multidisciplinary Diabetes Team Inpatient diabetes management committee Endocrinologists Pharmacy Nurse practitioner Hospitalist IM resident representative Diabetes educator - CDE Med/Surg nursing Critical care nursing Cardiac Surgery

24. 2008 ADA/EASD Type 2 Diabetes Guidelines

26. Patient-Centered Team Care Model

27. Patient-Centered Team Care Model

28. Physician-Rated Barriers to Optimal Diabetes Care

29. Key function of the multidisciplinary team The key function of a multidisciplinary team is to provide continuous, accessible and consistent care that is focused on the needs of individuals with type 2 diabetes: continuous: given the chronic nature of type 2 diabetes and its complications, it is important that diabetes care is maintained throughout the course of the disease accessible: it is important that healthcare professionals establish a rapport with patients so that they feel they can approach a member of the team whenever they need support consistent: spreading the responsibility for patient care over the whole multidisciplinary team helps to maintain high standards of care to help patients achieve their treatment goals and to maintain them in the long term. The key function of a multidisciplinary team is to provide continuous, accessible and consistent care that is focused on the needs of individuals with type 2 diabetes: continuous: given the chronic nature of type 2 diabetes and its complications, it is important that diabetes care is maintained throughout the course of the disease accessible: it is important that healthcare professionals establish a rapport with patients so that they feel they can approach a member of the team whenever they need support consistent: spreading the responsibility for patient care over the whole multidisciplinary team helps to maintain high standards of care to help patients achieve their treatment goals and to maintain them in the long term.

30. Establish a partnership between patient and healthcare professional Establishing a good rapport between the patient and healthcare professional is a critical first step for developing effective communication channels that will ultimately help to improve patient outcomes. It is important to involve the patient in the process at all stages by agreeing a mutual agenda, with the common goal of managing their condition effectively in order to maintain best possible health. This involves working together to discuss how implementing behavioral changes � such as adopting lifestyle changes, taking medications regularly and monitoring glycemia frequently � will have an important impact on outcomes, as well as building confidence that these goals are achievable. Two key factors include a mutual exchange of information between patient and healthcare professional coupled with a reduction in the resistance of the patient to change. Establishing a good rapport between the patient and healthcare professional is a critical first step for developing effective communication channels that will ultimately help to improve patient outcomes. It is important to involve the patient in the process at all stages by agreeing a mutual agenda, with the common goal of managing their condition effectively in order to maintain best possible health. This involves working together to discuss how implementing behavioral changes � such as adopting lifestyle changes, taking medications regularly and monitoring glycemia frequently � will have an important impact on outcomes, as well as building confidence that these goals are achievable. Two key factors include a mutual exchange of information between patient and healthcare professional coupled with a reduction in the resistance of the patient to change.

31. Helping patients to accept their condition Individuals with type 2 diabetes often have anxieties about their condition, linked with a fear of the unknown. This may manifest itself as a sense of grieving or loss.1 It is important that healthcare professionals support the patient in acknowledging their change in health status. This will help them to come to terms with their condition and prepare them to do whatever is required to best improve their outlook. Structured patient education has been shown to improve patient understanding of their diabetes and increase awareness that lifestyle changes can affect outcomes.1,2 1Lacroix A, et al. Schweiz Rundsch Med Prax 1993; 82:1370�1372. 2Skinner TC, et al. Diabetic Med 2005; 22 (Suppl. 2):1�121. Individuals with type 2 diabetes often have anxieties about their condition, linked with a fear of the unknown. This may manifest itself as a sense of grieving or loss.1 It is important that healthcare professionals support the patient in acknowledging their change in health status. This will help them to come to terms with their condition and prepare them to do whatever is required to best improve their outlook. Structured patient education has been shown to improve patient understanding of their diabetes and increase awareness that lifestyle changes can affect outcomes.1,2 1Lacroix A, et al. Schweiz Rundsch Med Prax 1993; 82:1370�1372. 2Skinner TC, et al. Diabetic Med 2005; 22 (Suppl. 2):1�121.

32. The need to establish a good rapport These quotations illustrate the difference between establishing a good and bad rapport between healthcare professional and patient. In the first example, the patient and healthcare professional have built a good relationship involving a two-way exchange of views leading to mutual respect and agreement regarding the optimal treatment for the patient�s lifestyle. In the second example, the patient has no control over the discussion and his specialist offers advice without considering how this will fit into the patient�s lifestyle. These quotations illustrate the difference between establishing a good and bad rapport between healthcare professional and patient. In the first example, the patient and healthcare professional have built a good relationship involving a two-way exchange of views leading to mutual respect and agreement regarding the optimal treatment for the patient�s lifestyle. In the second example, the patient has no control over the discussion and his specialist offers advice without considering how this will fit into the patient�s lifestyle.

33. Diabetes Self Management Classes American Diabetes Association-Certified since 1999 Individual education. Insulin pump training. Monthly classes offering 8 hours of diabetes information and education for patients. Saturday classes offering 8 hours of diabetes information and education for patients. Follow Up Classes offering 1-2 hours of continuing education for class participants. From January 2006 to October 2006: 9 Monday & Tuesday classes 9 Follow Up Classes 2 Saturday ClassesFrom January 2006 to October 2006: 9 Monday & Tuesday classes 9 Follow Up Classes 2 Saturday Classes

34. Diabetes Support Groups Type 2 Diabetes Support Groups monthly Type 1 Diabetes Support Groups offered periodically Psychosocial Support Groups with psychologist monthly January to October 2006: 5 type 1 support groupsJanuary to October 2006: 5 type 1 support groups

35. Education plays an important role in managing patients with diabetes. Patient education should be individualised, and may involve a structured, timetabled education programme. Educating patients about diabetes improves their involvement, and can help improve glycaemic control as shown by this meta-analysis and meta-regression of randomised controlled diabetes patient education trials. Ellis S, et al. Patient Educ Couns 2004;52:97?105. Education plays an important role in managing patients with diabetes. Patient education should be individualised, and may involve a structured, timetabled education programme. Educating patients about diabetes improves their involvement, and can help improve glycaemic control as shown by this meta-analysis and meta-regression of randomised controlled diabetes patient education trials. Ellis S, et al. Patient Educ Couns 2004;52:97?105.

36. Diabetes Education My secret weapon for improved glycemia Diabetes Education Program

37. Patient education can lead to improved glycemic control

38. Impact of a multidisciplinary team on glycemic control and hospital admissions This study evaluated a multidisciplinary team approach (involving a diabetes specialist nurse, psychologist, nutritionist and pharmacist) compared with standard diabetes care provided by primary care physicians in a health maintenance organization (HMO) setting over a 6-month time period.1 Both HbA1c levels and hospital admissions decreased significantly with the multidisciplinary team approach.1 HbA1c levels decreased by 1.3% in the multidisciplinary group compared with 0.2% in control subjects (P < 0.0001) at 6 months post-randomization. Hospitalizations were 80% more frequent in control subjects compared with the multidisciplinary group during the 17�18 months following randomization (P = 0.04). 1Sadur CN, et al. Diabetes Care 1999; 22:2011�2017.This study evaluated a multidisciplinary team approach (involving a diabetes specialist nurse, psychologist, nutritionist and pharmacist) compared with standard diabetes care provided by primary care physicians in a health maintenance organization (HMO) setting over a 6-month time period.1 Both HbA1c levels and hospital admissions decreased significantly with the multidisciplinary team approach.1 HbA1c levels decreased by 1.3% in the multidisciplinary group compared with 0.2% in control subjects (P < 0.0001) at 6 months post-randomization. Hospitalizations were 80% more frequent in control subjects compared with the multidisciplinary group during the 17�18 months following randomization (P = 0.04). 1Sadur CN, et al. Diabetes Care 1999; 22:2011�2017.

39. Impact of implementing an educational program via a multidisciplinary team This study indicates the benefits of implementing an educational program designed and adapted to local conditions by a multidisciplinary group of healthcare professionals.1 By 12 months after implementation of a structured educational program, all parameters had improved significantly (P < 0.001), including: fasting plasma glucose HbA1c body weight systolic blood pressure diastolic blood pressure cholesterol triglycerides. These findings reinforce the value of education as an essential component of diabetes care. 1Gagliardino JJ, et al. Diabetes Care 2001; 24:1001�1007.This study indicates the benefits of implementing an educational program designed and adapted to local conditions by a multidisciplinary group of healthcare professionals.1 By 12 months after implementation of a structured educational program, all parameters had improved significantly (P < 0.001), including: fasting plasma glucose HbA1c body weight systolic blood pressure diastolic blood pressure cholesterol triglycerides. These findings reinforce the value of education as an essential component of diabetes care. 1Gagliardino JJ, et al. Diabetes Care 2001; 24:1001�1007.

40. A multidisciplinary team can reduce costs This study indicates the benefits of implementing an educational program designed and adapted to local conditions by a multidisciplinary group of healthcare professionals.1 By 12 months after implementation of a structured educational program, the decrease in pharmacotherapy required for control of diabetes, hypertension and hyperlipidemia represented a 62% decrease in the annual cost of treatment (US$107,940 versus US$41,106). After deducting the additional cost of urine glucose monitoring (US$30,604), there was still a 34% annual saving in treatment costs. 1Gagliardino JJ, et al. Diabetes Care 2001; 24:1001�1007.This study indicates the benefits of implementing an educational program designed and adapted to local conditions by a multidisciplinary group of healthcare professionals.1 By 12 months after implementation of a structured educational program, the decrease in pharmacotherapy required for control of diabetes, hypertension and hyperlipidemia represented a 62% decrease in the annual cost of treatment (US$107,940 versus US$41,106). After deducting the additional cost of urine glucose monitoring (US$30,604), there was still a 34% annual saving in treatment costs. 1Gagliardino JJ, et al. Diabetes Care 2001; 24:1001�1007.

41. Diabetes Multidisciplinary Team leads to improved glycemic control:The HbA1C % at baseline & 6 months

42. Shared Medical Appointments (SMA) January to October 2006: 15 SMA�sJanuary to October 2006: 15 SMA�s

43. WHAT IS A SHARED MEDICAL APPOINTMENT? 90 minutes group visit of 9-12 established patients for the follow up care of diabetes and are staffed by Endocrinologist Diabetic Educator Nurse Visit Type follow-up appointments

44. Understanding SMA During the visit the physician perform a series of one-on-one patient encounters in a group setting and manage and advise each patient in front of the others. A behaviorist runs the discussion and educates when the physician is documenting or performing exams. Behaviorist: May be a CDE, ARNP, or Nutritionist.

45. Room Diagram: Group Medical Appointment

46. Shared (SMA) vs. Individual (IA) Diabetes Visits AMGA Patient Satisfaction Survey

48. Group Visits Improve Metabolic Control in Type 2 Diabetes

49. Diabetes Outcomes

50. Diabetes Outcomes

51. Diabetes Outcomes

52. Diabetes Outcomes

53. Cleveland Clinic Florida: SMA Patient Satisfaction Survey

54. Need for shared responsibility/ common philosophy for achieving glycemic goals

55. Additional functions of a multidisciplinary team Provide input at diagnosis of condition and continually thereafter to: agree standards of care discuss rational therapeutic suggestions monitor guideline adherence and short-term outcomes avoid early complications or provide timely intervention to decrease diabetes-related complications Enable long-term patient self-management If properly implemented, a multidisciplinary approach to diabetes care is cost-effective and improves quality of care compared with individual patient�physician care.1 In addition to ensuring that treatment goals are maintained, the team approach helps to implement: patient satisfaction and self-management the development of a community support network team coordination and communication patient follow-up and outcome evaluations. 1Codispoti C, et al. J Okla State Med Assoc 2004; 97:201�204.If properly implemented, a multidisciplinary approach to diabetes care is cost-effective and improves quality of care compared with individual patient�physician care.1 In addition to ensuring that treatment goals are maintained, the team approach helps to implement: patient satisfaction and self-management the development of a community support network team coordination and communication patient follow-up and outcome evaluations. 1Codispoti C, et al. J Okla State Med Assoc 2004; 97:201�204.

56. Other benefits of a multidisciplinary team approach to type 2 diabetes care Several studies have investigated the impact of a multidisciplinary team approach to diabetes care and demonstrated the merits of this approach in providing effective management of diabetes. Benefits of the multidisciplinary approach include: improved glycemic control1,2 and quality of life1 increased patient follow-up1 higher patient satisfaction1 lower risk of complications2 decreased healthcare costs.2 1Codispoti C, et al. J Okla State Med Assoc 2004; 97:201�204. 2Gagliardino JJ & Etchegoyen G. Diabetes Care 2001; 24:1001�1007.Several studies have investigated the impact of a multidisciplinary team approach to diabetes care and demonstrated the merits of this approach in providing effective management of diabetes. Benefits of the multidisciplinary approach include: improved glycemic control1,2 and quality of life1 increased patient follow-up1 higher patient satisfaction1 lower risk of complications2 decreased healthcare costs.2 1Codispoti C, et al. J Okla State Med Assoc 2004; 97:201�204. 2Gagliardino JJ & Etchegoyen G. Diabetes Care 2001; 24:1001�1007.

57. Role of the multidisciplinary team

58. The multidisciplinary team requires Common goals Supportive/nurturing approach Commitment to principles of self care Good interpersonal skills of team members Clear definition of specific and shared responsibilities of team Tailoring of team members according to setting and resources It is important that the multidisciplinary diabetes care team has the following attributes: common goals a supportive/nurturing approach a commitment to principles of self-care good interpersonal skills of team members a clear definition of specific and shared responsibilities of team. Team members should be tailored according to settings, for example: primary versus secondary care rural versus urban special features, such as deprived areas.It is important that the multidisciplinary diabetes care team has the following attributes: common goals a supportive/nurturing approach a commitment to principles of self-care good interpersonal skills of team members a clear definition of specific and shared responsibilities of team. Team members should be tailored according to settings, for example: primary versus secondary care rural versus urban special features, such as deprived areas.

61. Patient-Centered Team Care Model

62. SATISFIED PATIENTS HAPPY PHYSICIANS

63. Thank You ! Questions Jose M. Cabral, MD CABRALJ@CCF.ORG 954-659-5271