The research on diabetes has shown the need to move from a traditional medical model to a patient-team orientation. This has led to a number of collaborative programs targeting the patient and family's comprehensive needs. This paper details one collaborative care program for underserved patients with Type-2 diabetes set in rural, eastern North Carolina. Roles of the therapeutic team are incorporated along with a case example highlighting the bio-psychosocial-spiritual model in action. Sustainability, challenges, and strengths are included to facilitate a realistic appraisal of the program.

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