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Omar Cruz, RN, is the discharge planning coordinator on the geriatric diabetic services team. He is also chair of the service’s Practice Council. Because of the changes stimulated by healthcare reform, the unit leadership has begun working on developing a continuum of care geriatric diabetic services model to ensure adequate services are available to these patients across their continuum of need.
Focusing on this population’s continuing healthcare needs requires Omar and his colleagues to reflect on which model of service might integrate the disciplines and link a variety of geriatric services in a model that would support geriatric diabetic patient care needs along the health continuum. The task appears complex and challenging, but Omar and his colleagues sense that it is the right priority to address.
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Because this task will require interdisciplinary team deliberation and decision making, who should be at the table? How do those individuals reflect the continuum of care for this patient population?
Because Omar and his team are building a continuum of care service structure for a specific patient population, which services will be provided for that population? How do they reflect the continuum of care for this population?
What is the role of the nurse both in the development of this continuum of care model and its integration?

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