Hello, everyone. I'm Mayra Camposado and I'm excited to continue this conversation and shift now the focus to how a multidisciplinary team approach combined with referral criteria can work together to optimize patient outcomes through team-based care. When managing chronic conditions like diabetes, CKD, and cardiovascular disease, it's clear that no single provider can do it all. These complex conditions require a coordinated team-based approach where each team member plays an important role in improving patient outcomes and enhancing quality of life. In this final section, we're going to explore why a multidisciplinary team is essential, what this team can look like in a real-world setting, the importance of clear, consistent referral pathways, and how all these pieces come together to close care gaps, improve communication, and drive earlier, more effective interventions. Working closely with diverse care teams in both a clinical and academic settings, I've seen firsthand how team collaboration can improve patient outcomes. So let's take a closer look at how we can structure and support a multidisciplinary team approach that truly meets our patients where they are. So why is a multidisciplinary team approach not just helpful but essential when it comes to caring for patients with diabetes, CKD, and cardiovascular disease? As we know, these patients often live with a complex web of interrelated conditions, and trying to manage them in silos or through a single provider lens simply isn't enough. So let's break down a few of the key challenges we face in delivering optimal care within our healthcare system to our patients. We have that high patient complexity. These patients rarely present with just one issue. They often live with multiple comorbidities that influence each other, like diabetes affecting CKD and further complicating cardiovascular risks, as we saw earlier in our presentation. Managing one without accounting for the others can lead to gaps, setbacks, or even harm to our patients. A team approach ensures that we're treating the whole patient, not just one condition. When it comes to delayed referrals, time matters. When referrals to specialist, education services, or care programs are delayed, disease progression accelerates. We miss critical windows for intervention, leading to higher complications, cost, and patient distress. Timely, coordinated referrals are key. Fragmented care. Without a connected care team, patients may receive inconsistent or even conflicting guidance. They're taking the same medications, they can miss follow-ups, or even have overlooked labs. This disconnect puts both the patient and provider both at risk and often leads to poor outcomes and frustrations. Communication barriers. At the heart of team-based care is communication. When we don't communicate clearly with each other or even with our patients, we see breakdowns in care, reduced adherence, and a loss of trust from patients to providers. All these challenges lead us to one clear solution. A strong, multidisciplinary team approach with defined roles, clear communication pathways, and a streamlined referrals to specialists. That's how we ensure each patient receives the right care at the right time from the right expert. Now that we've looked at the challenges, let's shift to the benefits of a team-based approach. First, timely identification and proactive management becomes possible. With multiple providers working together, we can detect complications earlier and deliver prompt, targeted interventions to slow disease progression before it's too late. We also see improved clinical outcomes, including better control of blood glucose, blood pressure, and lipids. Team-based care has also been shown to delay CKD progression and reduce the risk of cardiovascular events. Enhanced care coordination is another major benefit. Interdisciplinary teams are better equipped to share information, align treatment goals, and create unified patient-centered care plans. This leads to greater use of evidence-based therapies and leads to fewer gaps in care. Patients also become more engaged. Through personalized education and support, they're more likely to understand their treatment, follow through with recommendations, and be more involved in their care decisions. All of this can lead to fewer complications and hospitalizations. We've seen lower rates of diabetes-related hospital admissions and amputations rates with the use of a team-based approach. And finally, we can't overlook the impact a team-based approach can have on mental health and well-being. A supportive care team can promote emotional well-being by reducing stress and anxiety from our patients, therefore enhancing their quality of life. Together, these outcomes show why team-based care isn't just a model. It's a necessity for effective whole-person chronic disease management. Here's an example of what a multidisciplinary team may look like when managing patients with diabetes. While each of the roles may differ, it's important to remember that the patient should always remain at the center of the care that we provide. Depending on your practice setting, your multidisciplinary team may include fewer or even more team members, and that's perfectly acceptable. The key point is this. Every team member is essential, whether it's the primary care physician initiating the care, the endocrinologist optimizing that complex regimens, the cardiologist managing those cardiovascular risks, or the nephrologist guiding that renal care, even the pharmacist supporting medication management, or the certified diabetes care and education specialist delivering that critical diabetes education. Each of these team members bring something valuable to the table, and together they can improve patient outcomes. Now that we've seen what a multidisciplinary team might look like, it's also important to emphasize that timely referral to these team members is just as critical as the team itself. Referrals to specialists like endocrinologists, nephrologists, and cardiologists should not be delayed, especially when glycemic control is suboptimal or when complications such as CKD or cardiovascular disease begin to appear. This is where collaboration needs to shift from being a more reactive approach to more of a proactive one. The literature strongly supports that timely involvement of specialists improves patient outcomes, such as better glycemic control, slower progression of CKD, fewer cardiovascular events, and overall higher patient satisfaction, while on the contrary, having delayed referrals to specialists has been linked to increased hospitalization rates, and in some cases, higher mortality. Now that we understand the importance of timely referrals, let's look at a few key scenarios when referrals to specialists may be appropriate. Consider referring a patient to an endocrinologist if they are unable to achieve their target A1c despite multiple therapies, or if a patient is experiencing frequent episodes of hypo or hypoglycemia, or if a patient is on insulin management that's becoming very complicated. For cardiology, refer patients with a history of cardiovascular events such as an MI or stroke, or those that have high ASCVD risk scores greater than 20%, or that percent with signs and symptoms of heart failure. Referral to a nephrologist is recommended for patients that have persistent albuminuria, regardless of their CKD stage, or if there's a rapid decline in kidney function. Unfortunately, knowing the right time to refer isn't always straightforward. It can be challenging, especially when varying recommendations across different professional organizations exist. That's why clear and consistent referral guidelines are very important, as they can help minimize confusion and facilitate that timely evidence-based decision making. However, even when guidelines are in place, some providers may still hesitate or feel uncertain, and they often find themselves questioning, well, is this patient complex enough for a referral to a specialist? And the answer to that, and the key message to this, is this. If you feel your patient needs that additional support, then that's the right time to refer. Timely collaboration does not indicate a gap in your care. Rather, it reflects your commitment to providing the best possible care for your patients. Another critical yet often underutilized resource in diabetes care is diabetes self-management education and support, or for short, DSMES. Referring patients to DSMES is just as important as referring them to a specialist. These programs equip individuals with the knowledge, tools, and confidence they need to effectively manage their diabetes and improve their quality of life. Clinical guidelines recommend referring all individuals with diabetes to these services at the time of their diagnosis, annually, when treatment targets are not being met, when new complicating factors arise, or during significant life transitions. DSMES is delivered by a multidisciplinary team that may consist of physicians, advanced practice providers, pharmacists, nurses, dieticians, and other key members, all helping provide that essential diabetes education for patients. I wanted to share this diagram from an article published in Diabetic Medicine by John Wiley and Sons on behalf of Diabetes UK. It offers a visual framework for how we can improve the management of diabetes, chronic kidney disease, and cardiovascular disease. At the center is a patient with its care team, supported by integrated care cycles that include key components. As we can see, we have the interdisciplinary team that we spoke about, the importance of shared care protocols by having real-time data access through electronic health records, telehealth and digital health tools, which are critical for expanding access, especially in underserved or rural areas, policy models encouraging that standardized clinical guidance and staff training on the integrated care frameworks, and finally, but most importantly, patient-centered care, encouraging shared decision-making to align treatments with patient goals and the importance of having education at the level the patient needs and having that consideration of their cultural and personal values. Overall, this model reinforces that managing diabetes, CKD, and cardiovascular disease isn't just about treating disease in silos. It's about creating that connected systems of care that prioritize communication, access, and the individual needs of every patient. So, in summary, and some key takeaways, managing diabetes, kidney disease, and heart disease takes a true team effort. Establishing clear referral criteria can support timely referral to specialists, and in the end, a multidisciplinary team approach is not just helpful, but essential to delivering high-quality patient-centered care. Thank you for your time.

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