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The role of patient care teams in chronic disease management

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Edward H Wagner

Summary points

  • Effective chronic illness interventions generally rely on multidisciplinary care teams
  • Successful teams often include nurses and pharmacists with clinical and behavioural skills
  • Such teams ensure that critical elements of care that doctors may not have the training or time to do well are competently performed
  • These elements include population management, protocol based regulation of medication, self management support, and intensive follow up
  • The participation of medical specialists in consultative and educational roles outside conventional referrals may contribute to better outcomes

Resource: BMJ. 2000 Feb 26; 320(7234): 569–572.