Trans-Disciplinary Diabetes Care Model

A person with diabetes mellitus (DM) is often managed by a multidisciplinary care team, involving multiple appointments with doctor and nurse clinician, pharmacist, dietitian, podiatrist, social worker and others, to deliver various aspects of therapy and preventive care. The Clinical Diabetes Educator (CDE) programme at Tan Tock Seng Hospital (TTSH) was conceptualised to reduce care fragmentation, with the central idea of systematically cross-training and upskilling allied health professionals into CDEs to manage patients with diabetes under a transdisciplinary diabetes care model.

For this segment, we present a transdisciplinary model for diabetes care, describing not only the role of pharmacist–CDEs beyond the usual scope of practice, to provide holistic care and education to patients, but also how the transdisciplinary model value adds to patient care.