Running head: IP COLLABORATION AND DIABETES

Interprofessional Collaboration in Management of Type 2 diabetes with Attention to Social
Determinants of Health
Julia P. Torres, BSN, RN
Dr. Carol Moffett, PhD, RN, FNP-BC, CDE, FAANP
Arizona State University

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Abstract

Interprofessional collaboration (IP) is an approach used by healthcare organizations to improve
the quality of care. Studies examining effects of IP with patients with type 2 diabetes mellitus
(T2DM) have shown improvement in A1C, blood pressure, lipids, self-efficacy and overall
greater knowledge of disease process and management. The purpose of this project was to
evaluate the impact of IP with attention to identifying and addressing social needs of patients
with T2DM. Participants at least 18 years of age with an A1C >6.5% were identified; Spanish
speaking patients were included in this project. The intervention included administration of
Health Leads questionnaire to assess social needs. Monthly in person or phone meetings were
conducted during a 3-month period. The patient had the option to meet with the doctor of nursing
practice (DNP) student as well as other members of the team including the clinical pharmacist
and social work intern. Baseline A1C levels were extracted from chart at 1st monthly meeting.
Post A1C levels were drawn at the 3 month follow up with their primary care provider. Study
outcomes include the difference in A1C goal attainment, mean A1C and patient satisfaction. Pre
A1C levels in participants ranged from 7.1% to 9.8% with a mean of 8.3%. Post A1C levels
ranged from 6.9% to 8.6% with a mean of 7.7%. Two cases were excluded as they did not
respond to the intervention. A paired-samples t test was calculated to compare the mean pre A1C
level to the post A1C level. The mean pre A1C level was 8.24 (sd .879), and the post A1C level
was 7.69 (sd .631). A significant decrease from pre to post A1C levels was found (t (6) = 2.82,
p<.05). The prevalence of Type 2 Diabetes is on the rise, as are the costs. This nation’s
healthcare system must promote interprofessional collaboration and do a better job of addressing
SDOH to more effectively engage patients in the management of their disease.

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Keywords: Interprofessional Collaboration, Type 2 Diabetes, A1c, social determinants of
health

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Incorporating Interprofessional Care to Address Social Factors that Contribute to Diabetes
Disease Management
Diabetes Mellitus (DM) is now considered a pandemic that is affecting millions of people
worldwide (Meetoo, McGovern, & Safadi, 2007). People with diabetes are twice as likely
to have heart disease or a stroke, diabetic retinopathy, which can result in vision loss, kidney
damage, persistent infections, and lower limb amputations (CDC, 2016). Type 2 DM is a chronic
condition upon which social determinants of health have an impact. Per Walker, Smalls,
Campbell, Strom Williams, & Egede, (2014), studies have found associations among increased
incidence, prevalence and burden of disease with increasing levels of poverty and hunger
and lower levels of income and education. There is a need to gather more information on the
relationship between social determinants of health (SDOH) and diabetes.
Problem Statement
In the United States, an estimated 48.3 million people will be diagnosed with Type 2
diabetes by 2050 (ADA, 2017). Due to advances in treatment, individuals with diabetes are
living longer with their condition and its associated complications. It can be especially difficult
for someone to manage their chronic disease if they have unmet social needs such as
transportation, housing, food insecurity, and financial strain just to list a few. Leading studies
indicate social and environmental factors account for nearly 70 percent of all health outcomes
(Healthy People/Health Economy, 2015). Therefore, effective interventions are needed to assist
patients with their unmet social needs, in order to improve health outcomes, and reduce diabetesrelated complications.

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Background and Significance
Social Determinants of Health
Social determinants of health influence morbidity, mortality and functioning (Institute of
Medicine, 2002). These are conditions (e.g. social, economic, and physical) as well as
environments (e.g. school, church, workplace neighborhood, housing) that affect the quality of
life, functioning, and overall health of individuals (Healthy people, 2014). A study conducted by
Kollannoor-Samuel, et al., (2011), demonstrated that lower socio-economic status indicators
were associated with poorer fasting plasma glucose and HbA1C glycemic control. Lack of
affordable treatment can be a reason why patients, especially those with chronic conditions, do
not adhere to therapeutic recommendations. Patel et al., (2016) used data from the National
Health Interview Survey to identify the impact of perceived financial stress, financial insecurity
with health care, and food insecurity on cost-related nonadherence and found that financial
insecurity with healthcare and food insecurity were associated with a greater likelihood of costrelated nonadherence. A study by Seligman et al., (2012), found that participants with food
insecurity were significantly more likely than food-secure participants to have poorer glycemic
control. They also reported higher emotional distress related to diabetes. This is partially
attributed to increased difficulty following a diabetic diet and therefore feeling less capable of
being successful in managing their diabetes. Per Hill, Nielsen and Fox, (2013), “the incidence
and prevalence of Type 2 diabetes appear to be socially graded, as individuals with lower income
and less education are two to four times more likely to develop diabetes than more advantaged
individuals.” Furthermore, diabetes can decrease an individual’s productivity at work, which can
lead to employment related problems. This can cause the patient to feel stressed, which in turn

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can have negative effects on the body such as sleep problems, muscle tension and fatigue. (Hill
et al., 2013).
Government policymakers are also noticing social determinants and their relationship to
health outcomes. The Centers for Medicare and Medicaid Services’ (CMS) innovation initiative
is based on the Accountable Health Communities Model. The goal of this model is to address
health related social needs through achieving better clinical-community connections to improve
health outcomes and reduce costs (CMS, 2016). Screening for SDOH will facilitate
communication between the patient and provider and can link patients to appropriate low-cost
resources.
However, Garg, Boynton-Jarrett, and Dworkin, (2016) argue that screening for social
determinants of health can have unintended consequences. One barrier is that this process is
different from screening for medical problems for which diagnostic tools (eg. lab tests) are
available and routinely used by providers (Garg et al., 2016). In addition, providers may be
uncomfortable inquiring about social determinants due to lack of experience, inadequate training,
and perceived lack of time to address social needs during a standard 15-20-minute appointment.
Patients can become frustrated if expectations are not met. Per Garg et al., (2016) “screening for
any condition in isolation without the capacity to ensure referral and linkage to appropriate
treatment is ineffective and, arguably, unethical.”
Interprofessional Collaboration
Typically, standard treatment practices for patients with diabetes include a review of
systems, focused exam, medical management with brief instruction, and follow-up in three
months (Jessee & Rutledge, 2012). However, conventional treatment strategies need to improve.
A study evaluating the effectiveness of a coordinated team group visit for T2DM found that

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participants had better clinical outcomes including improved fasting blood glucose and HgA1c,
greater knowledge and better self-efficacy than those that received standard care (Jessee &
Rutledge, 2012). Another study also implemented a multidisciplinary approach consisting of
five 15-minute appointments with a diabetic educator, nutritionist, pharmacist, nurse
practitioner/endocrinologist, and psychologist at a diabetes management clinic in Phoenix,
Arizona. A retrospective chart review found significantly reduced HbA1c, diastolic blood
pressure and an increase in the percentage of patients meeting blood pressure goals of
<140/90mmHg (Buckley, et al., 2014). An added benefit to an interprofessional approach like
the ones described above is that group visits aid in the prevention of T2DM by addressing
hypertension, hyperlipidemia, and obesity. Barceló et. al., (2010) conducted a study that
evaluated an interprofessional coordinated care approach versus the standard of care for diabetic
patients in Mexico. Results showed a statistically significant improvement in A1C levels of
participants that were in the coordinated care intervention group. A study by Hutchinson (2014)
evaluated if using an interprofessional care team improved diabetes outcoming in underserved
populations. Results found that using an interprofessional care team had significant
improvements in health outcomes including a 10% improvement in HgA1c, a 9% improvement
in systolic blood pressure and a 62.6% reduction in triglycerides. Another study showed that
integrated care was associated with a 20% improvement in glycemic control among patients with
T2DM (Al Asmary et al., 2013). Interprofessional collaboration is a fairly new process, but the
literature shows that it can have a positive impact on various outcomes for patients and
professionals.
The Interprofessional Education Collaborative Expert Panel (2011) guides healthcare
organizations and providers in understanding the core competencies of an interprofessional

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collaborative practice. A benefit to implementing interprofessional collaboration is that
healthcare professionals will shift the way they think and interact with one another as well as
learn to recognize that each professional’s expertise is valid and important to address the needs
of the client/family/population (WHO, 2010). An interprofessional approach can also address
barriers expressed by patients, such as excessive wait times for appointments. Who will be part
of the coordinated care team will depend on the practice and chronic disease. The team can
include primary care providers, (physicians, nurse practitioners, physician assistants), behavioral
health specialists, pharmacists, social workers, and physical and occupational therapists.
However, there are barriers to implementing an interprofessional approach. One of these
barriers is scope of practice restrictions. For example, legislation can limit a podiatric foot and
ankle surgeon to only address issues below the ankle and not be allowed to perform surgery
adjacent to the ankle. There is also resistance from providers who have traditionally treated
certain conditions and do not want to use other providers of the healthcare team. This must
change to properly address the diabetic epidemic in the United States and provide the best care to
patients with diabetes.
Internal Evidence
Currently at a Southwestern medical facility, Medicare patients are given a health risk
assessment (HRA) tool to fill out when they are new to the practice. The HRA questionnaire
addresses self-assessment of health status, physical/mental functioning, behavioral risks (e.g.
tobacco use, diet, alcohol consumption, physical activity, motor vehicle safety), and
psychological risks (e.g. stress, social isolation, pain/fatigue). This assessment is placed in the
chart for providers to use and review. However, many patients do not have this assessment on
their chart and providers do not use it as standard practice with their patients. There is not an

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effective screening tool in place to identify social needs, which would then prompt a referral to
the interprofessional care team project that is currently taking place.
Interprofessional coordinated care is an innovative approach that has the potential to
address not only the biological component of a chronic disease, but also address social
determinants of health to produce better treatment outcomes for populations living with chronic
illness such as T2DM.
PICOT Question
Conventional treatment strategies, which include a single provider approach are costly
and most of the time patients are referred to other specialists, which results in added costs to the
patient. In addition, a process to screen for social determinants of health may result in
improvement of an individual’s ability to manage their health conditions once they leave the
medical office. This inquiry has led to the clinically relevant PICOT question: In patients with
Type 2 diabetes mellitus (T2DM), how does an interprofessional approach to addressing social
determinants of health (SDOH), as compared to a single provider approach, impact HbA1c?
Search Strategy
An exhaustive review of the literature was performed, including an electronic database
search and scanning of reference lists to answer this question. Four databases were searched:
CINAHL, Pubmed, Scopus and Medline. Key words used in each database search included:
(‘interprofessional’ or ‘interprofessional relations’ [MeSH terms] or ‘multidisciplinary’ or
‘collaborative care’ or ‘team based’) AND (‘treatment outcome’ [MeSH terms] or ‘outcome
assessment’ [MeSH terms]) AND (‘Diabetes Mellitus, Type 2’ [MeSH terms]) AND (‘social
determinants of health’ [MeSH terms]). Each keyword was searched independently yielding at
times thousands of results. The keywords were then combined, and limits were placed. Overall,

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30 studies were initially reviewed for inclusion in the literature review but after completing rapid
critical appraisals on the studies, only ten were chosen that met the criteria and addressed the
components of the PICO question. The ten studies were reviewed and organized into evaluation
and synthesis tables. Three systematic reviews, two qualitative studies, one randomized control
trial, two quasi-experimental studies, one retrospective and one cross sectional study. All articles
required a medical diagnosis of diabetes however each study had different inclusion criteria for
HbA1c parameters. There was a moderate degree of heterogeneity in tools used for
measurement. However, all studies evaluated HbA1c which is well known validated blood test.
Patient satisfaction in regard to care received also was assessed. For all studies, the sample
populations inclusion criteria only included adults 18 years and older. The mean age ranged
from 55-65 in 8 of the studies. One of the qualitative studies evaluated the process of
interprofessional collaboration among healthcare workers and therefore the mean age is younger.
The composition on the care team varied among the studies. A combination of diabetic
educators, providers, behavioral therapists and podiatrists were used. Five major outcome areas
were noted: A1c, blood pressure, lipid profile, self-efficacy, and quality of life. The remainder of
the measured outcomes exhibited heterogeneity.
Evidence Summary Supporting Project
In adults with T2DM, interprofessional collaboration will positively impact HbA1c
levels. The difficulty with this process is that interprofessional collaboration is done differently
among various practices. There is not a standardized process in evaluating an individual’s social
needs. However, this gives flexibility to create a collaborative team that is appropriate for the
clinical setting and population. In addition, several studies showed that by working in an
integrated team, patients had a reduction in weight, lipid levels, and blood pressure. Patients also

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had higher satisfaction in the care they received in teams versus traditional care. In addition,
SDOH also have an impact on health outcomes in patients with T2DM. Therefore, evaluating
SDOH with T2DM will be a vital component of the interprofessional care the patient will
receive. A social worker will be an important professional to include in any interprofessional
care team to address unmet social needs a patient may have. Synthesis table (Appendix A) is
available for review of all 10 critically appraised studies.
Purpose and Rationale
The purpose of this project is to determine the impact of interprofessional collaboration
on diabetes disease management and how it may assist health providers in better addressing
social determinants of health and achieving overall improved health outcomes.
Contribution of Theory Conceptual Framework to Utility of Evidence
The Chronic Care Model (CCM) was created in 1998 to address the deficiencies of a
healthcare system that was not properly addressing patients with chronic conditions. The CCM
model represents an approach that reconstructs medical care through partnerships between health
systems and communities. There are six components to the CCM (Appendix B): 1) health
system- organization of health care), 2) self-management support, 3) decision support, 4)
delivery system design, 5) clinical information systems, and 6) community resources and policies
(Stellefson, Dipnarine, & Stopka, 2013). A systematic review conducted by the Centers for
Disease Control and Prevention and results indicate the CCM approaches are effective in
managing diabetes in US primary care settings (Stellefson et al., 2013). Therefore, this model
will be used as a framework for the project. This project has components of the CCM integrated
such as having monthly visits with patients willing to participate to provide self-management
support. The social work intern will be able to provide the patient with community resources and

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policies. The interprofessional team will provide coordinate care and remove barriers to care by
working together as a team.
Evidence Based Practice Model
The Rosswurm and Larrabee Model for Evidence-Based Practice Change was chosen to
guide this project. This model is comprised of six steps (See appendix C for diagram of model).
The first step is to assess the need for change in practice. There is opportunity for improvement
of a current interprofessional team project that is underway. An assessment of internal and
external data shows that interprofessional collaborative teams have an impact on patient’s health
outcomes including HbA1c and patient satisfaction. There is a need to better identify and address
SDOH. The second step is to locate the best evidence. The search strategy was described above,
and rapid critical appraisals forms were used to evaluate the evidence. Step three is to critically
analyze the evidence. Synthesis of the evidence was done in order to evaluate if the body of
evidence supports a practice change. Step four is to design practice change. It will be important
to clearly define the proposed practice change, and outcomes and resources will need to be
defined. Step four includes the implementation of the intervention by means of a pilot study.
Adjustments can be made by using feedback if necessary. The last step is to integrate the change
into practice. Staff in-service education was provided to reinforce implementation of the new
practice change. Ongoing monitoring can be used to identify any refinements in the new practice
(Rosswurm and Larrabee, 1999).
Methods
This project was a continuation of a previous project started in the fall of 2017. The
previous student found that there is a need for team-based care for individuals with type 2
diabetes in this primary care practice.

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Statement of Ethical Approval
Upon approval from site privacy board and Arizona State University Institutional Review
Board, patients were given the Health Leads Questionnaire to assess for social needs by medical
assistants. All project participants gave written consent prior to taking part of the project.
Participants and Setting
Patients were eligible for this project if they met the following criteria: (a) 18 years of age
or older, (b) active diagnosis of Type 2 Diabetes, (c) A1C >6.5%, (d) English or Spanish as
primary language. This project took place in a primary care facility in the Southwestern United
States
Study Design and Intervention
The following health care professionals were part of this project in order to promote
interprofessional collaboration: DNP student, primary care physician, clinical pharmacist, and
Master of Social Work (MSW) student. The Health Leads questionnaire consisted of 10 yes/no
clinically validated health questions pulled from the following sources: Veterans Administration
Questionnaire, Children’s Health Watch Survey, Behavioral Risk Factor Survey, U.S.
Department of Justice, Survey of Income and Program Participation, STOFHLA tool, and the
USDA Household Food Survey (Health Leads, 2016). During the office visit, the primary care
provider reviewed patient’s current A1C level. Afterward, the questionnaires were reviewed by
the DNP student. Patients and their families were invited to spend one day or more a month for a
total of 3 months in meetings with the DNP student and if needed, other members of the
collaborative team. During the first meeting, written consent was obtained, and the DNP student
gave diabetes counseling. Patient specific goals were established and if the patient had any

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unmet social needs, the DNP student referred them to the MSW student. The clinical pharmacist
would send weekly data of patients that met criteria for screening; she was also available for
medication counseling. Subsequent monthly meetings were done in person or via phone,
whichever was most convenient for the patient. Goals were re-evaluated and if any unmet social
needs arose during conversation, the patient was referred to the MSW student again. A postintervention A1C was measured during the patient’s 3-month follow up visit with primary care
provider. This project did not have a proposed budget in place as community resource list was
already established by the facility and interprofessional care team did not receive compensation
for being part of the team.
Project Results
A total of 69 patients were given the Health Leads questionnaire by the medical
assistants. Out of the 69 patients who completed the questionnaire, 19 consented to participate in
the project. Seven of the participants were female (36.8%) and twelve were male (85.7%). A
total of fifteen participants were Hispanic (78.9%) and four patients were Caucasian (21.1%).
Participants age ranged from 41 to 86 with a mean age of 66. Six (31.6%) participants spoke
Spanish as their primary language.
The following social needs were identified through the Health Leads Questionnaire: “In
the last 12 months, did you ever eat less than you felt you should because there wasn’t enough
money for food?”, with 5.3% answering positively (n=1); “Are you worried that in the next 2
months you may not have stable housing?”, with 5.3% answering positively (n=1); “In the last
12 months, have you needed to see a doctor but could not because of cost, with 15.8% answering
positively (n=3); and “Do you ever need help reading hospital materials?”, with 36.8 %
answering positively (n=6). The participants were referred to the MSW student for assistant with

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these social needs. A total of nine participants (n=9) completed the 3-month project; the rest
were lost to attrition.
Pre and Post intervention A1C levels were measured. Pre A1C levels ranged from 7.1%
to 9.8% with a mean of 8.3%. Post A1C levels ranged from 6.9% to 8.6% with a mean of 7.7%.
Two cases were excluded as they did not respond to the intervention. A paired-samples t test was
calculated to compare the mean pre A1C level to the post A1C level. The mean pre A1C level
was 8.24 (sd .879), and the post A1C level was 7.69 (sd .631). A significant decrease from pre to
post A1C levels was found (t (6) = 2.82, p<.030).
Discussion
Overall this project had a positive impact on patients A1C levels. Of the nine participants
that completed the project, two had an increase in the post A1C levels. This project was
completed over the holiday season which both participants stated as a reason for a rise in A1C
levels as they overindulged in holiday foods & drinks. High attrition rate was also noted. The
DNP student made several attempts to follow up via phone but was unsuccessful. Participants
who did answer the phone call stated life events such as caring for loved ones, moving, change in
insurance health plans, and lack of time off from work, as reasons for not coming in for 3-month
follow up. Thus, a longer project time frame would be helpful in decreasing attrition rate as more
time would allow participants to come in for follow up.
Regarding the impact this project had on the provider level, patients expressed a greater
understanding of Type 2 diabetes disease process and management when receiving information
in their native tongue.

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After completion of this project, the primary care office supervisor agrees that screening
of social needs should be implemented system wide. However, this facility will need to decide
who will be designated to review the screening forms and refer the patient to the social worker
for assistance with their social needs. Although universal screening of social needs was the goal,
the Health Leads questionnaire was not given to all eligible patients, which contributed to low
recruitment. Barriers to implementation of universal screening via the Health Leads
questionnaire included acceptance from Medical Assistants (MA) of this new task, perception of
importance of giving questionnaire to patient, and overall motivation to screen every eligible
patient. Including key individuals such as the clinical manager in universal screening
implementation may improve this barrier.
On a separate note, the Health Leads questionnaire identified the need for accessible and
affordable dental services. A study evaluating individuals with diabetes and periodontal disease
receiving care at all Veterans Administration medical centers and clinics in the United States
showed that long-term periodontal care improves long-term glycemic control among individuals
with type 2 diabetes (Merchant et al., 2016). Currently, Arizona’s Medicaid agency, Arizona
Health Care Cost Containment System (AHCCCS) covers emergency dental care with
AHCCCS- contracted dentists for adults age 21 and older (max $1,000/year) (AHCCCS, 2017).
Unfortunately, preventative dental care and other dental treatments like root canals are not
covered. Dental care is crucial for patients that have type 2 diabetes; therefore, policy makers in
Arizona should continue to work on improving the affordability of dental services, especially for
the underserved.

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Conclusion
According to the CDC, in 2006 the United States spent over $7,000 dollars per person,
more than twice the average of 29 other developed countries in health-related expenditures
(CDC, 2009). As a healthcare system, we have made tremendous progress in developing and
using effective screening interventions such as mammograms, colon cancer screening, and
cervical screening to name a few. However, our healthcare system is remains essentially reactive.
Individuals tend to seek care if they have an illness, injury or bothersome symptom. However,
primary care offices have an opportunity to address unmet social needs, especially with patients
with chronic conditions. Without a strategic standardized screening process, patient’s social
needs will continue to negatively impact their ability to manage their chronic disease. The
diabetes disease price tag in the US for 2012 was $245 billion (ADA, 2013). These costs will
continue to rise and be very costly to society. Therefore, it is the hope of this project to provide a
systematic approach to assessing SDOH with the use of an interprofessional care team in order to
improve the patient’s ability to better manage their chronic disease.

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Running head: IP COLLABORATION AND DIABETES

23
Appendix A

Table 1
Synthesis Table
Zwarenstein

Year
Design:
SR
CSS
RCT
QES
Qualitative
Retrospective
Setting:
Community
Hospital
Alliance grantee
sites
Outpatient
teaching hospital

Time

PC
FG

2009

Walker

2014

X

Walker

Author
Jessee

Korner

2014

2016

X

X

Study
Characteristics
2012

Gucciardi

2016

Fitzgerald

2017

X

Brown

2016

Bishay

2013

Al
Asmary

2013

X
X
X

X
X

X
X

X
X

X

X
X

X

X

X

X
X

X

X
X

12
months

38.4%

Population
Demographics
3 months

1 year
period

!00% DE
43.8% PCP

5 year
period

6 month
pilot

Full study
program
was 30
months

Max 6
months

37%
IDEAS

55%

58.5%

CG- comparison group, CHW- community health worker DSME- diabetic self-management education, DV- dependent variable, DE-diabetic educators, ECexclusion criteria FG= female gender, GMV: group medical visits, HgA1c- glycated hemoglobin, HP- healthcare professional, IDEAS-Integrated diabetes
education and assessment service, IC: inclusion criteria IPC-interprofessional collaboration, IG-intervention group, IPT- interprofessional teamwork IV=
independent variable, MG= male gender, MMSE- mini mental status exam NPCT- Nurse practitioner coordination team PCP-primary care physician, QESquasi-experimental study, RCT- randomized control trial, SDOH- social determinants of health, SS- #of study sites, T2DM- Type 2 Diabetes Mellitus

IP COLLABORATION AND DIABETES

24
28%
Hospital
Independent
Variables

SDOH
IPC (“team
interventions,
multidisciplinary
interventions”)

HbA1c
Fasting glucose
Waist
circumference
Blood pressure
Lipid profile
Self-efficacy
Patient
satisfaction
QOL

X
X

X

X

X

X

X

X

Measurable
outcomes
X
X

X

X

X

X

X

X

X

X

X

X
X

X
X
X
X

X
X

X
X
X

X

X
X

X

X
X

CG- comparison group, CHW- community health worker DSME- diabetic self-management education, DV- dependent variable, DE-diabetic educators, ECexclusion criteria FG= female gender, GMV: group medical visits, HgA1c- glycated hemoglobin, HP- healthcare professional, IDEAS-Integrated diabetes
education and assessment service, IC: inclusion criteria IPC-interprofessional collaboration, IG-intervention group, IPT- interprofessional teamwork IV=
independent variable, MG= male gender, MMSE- mini mental status exam NPCT- Nurse practitioner coordination team PCP-primary care physician, QESquasi-experimental study, RCT- randomized control trial, SDOH- social determinants of health, SS- #of study sites, T2DM- Type 2 Diabetes Mellitus

Running head: IP COLLABORATION AND DIABETES
Appendix B
Figure 1

25

IP COLLABORATION AND DIABETES
Appendix C
Figure 2

26