Coordinating Care for Success—Finding a Pathway with Your Health Care Team

Team-Based Diabetes Care Imperative

Diabetes now affects over 38 million Americans, with incidence climbing due to aging populations, obesity trends, and social determinants like food insecurity. Effective management increasingly requires input from multiple specialists—endocrinologists, registered dietitian nutritionists, pharmacists, behavioral health providers, and others—rather than relying solely on primary care physicians.

The ADA's Standards of Care in Diabetes—2026, published in late 2025, reinforce this shift. Updates highlight person-centered, collaborative models that integrate long-term treatment for diabetes alongside comorbidities such as cardiovascular and kidney disease. Enhanced tables specify additional team members, particularly for older adults, and stress avoiding therapeutic inertia through timely adjustments in therapy, technology, and support systems.

Real-world stakes are high. Poor coordination contributes to uncontrolled hyperglycemia, raising risks of hospitalizations, amputations, blindness, and cardiovascular events. Annual diabetes-related medical costs exceed $400 billion in the US, with a substantial portion tied to preventable complications. Inaction or siloed care exacerbates disparities, especially in underserved communities where access to multidisciplinary teams remains limited.

Non-obvious tensions include balancing cutting-edge tools—continuous glucose monitors, automated insulin delivery, and GLP-1 receptor agonists—with practical team coordination. While these innovations improve outcomes, they demand seamless data sharing and communication to prevent errors or patient overload. Primary care teams often lack capacity for complex cases, yet specialist referrals face delays, creating bottlenecks. Moreover, expanding team roles risks diluting focus unless health systems invest in quality improvement and interoperability.

Broader pressures stem from evolving payment models and policy pushes for value-based care, which reward coordinated outcomes but penalize fragmentation. The timing aligns with post-pandemic recognition of chronic disease vulnerabilities and recent guideline evolutions incorporating evidence from new trials on integrated approaches.