Organised multidisciplinary team care
A second core component of the HealthOne NSW Model of Care is multidisciplinary team care provided by general practice, community health and other health and community care professionals as necessary.
The following definition outlines the objectives as well as some of the challenges involved in achieving this component.
"Multidisciplinary care when professionals from a range of disciplines work together to deliver comprehensive care that addresses as many of the patient's needs as possible. This can be delivered by a range of professionals functioning as a team under one organisational umbrella or by professionals from a range of organisations, including private practice, brought together as a unique team. As a patient's condition changes over time, the composition of the team may change to reflect the changing clinical and psychosocial needs of the patient."
Mitchell, G.K., Tieman, J.J. & Shelby-James, T.M. (2008). Multidisciplinary care planning and teamwork in primary care. MJA, 188(8), p.S63.
A HealthOne NSW Multidisciplinary Team
A multidisciplinary team involves a range of health professionals, from one or more organisations, working together to deliver comprehensive patient care. The ideal multidisciplinary team for the delivery of the HealthOne NSW Model of Care includes:
- General practitioners
- Practice nurses
- Community health nurses
- Allied health professionals (may be a mix of state funded community health and private professionals) such as physiotherapists, occupational therapists, dietitians, psychologists, social workers, podiatrists and Aboriginal Health Workers
- Health educators - such as diabetes educators
Multidisciplinary teams convey many benefits to both clients and the health professionals working on the team, such as improved health outcomes and enhanced satisfaction for clients; and the more efficient use of resources and enhanced job satisfaction for team members.
To ensure optimum functioning of the team and effective patient outcomes, the roles of the multidisciplinary team members in care planning and delivery must be clearly negotiated and defined (Mitchell et al 2008). This will require consideration of:
- respect and trust between team members
- the best use of the skill mix within the team
- what clinical governance structures need to be in place
- how communication and interaction will occur between team members
These are complex issues and can involve significant change to work practices and organisational arrangements and will require multifaceted implementation strategies (Mitchell et al 2008). These issues are further explored in the Workforce Development section.
References of interest
Dennis SM, Zwar N, Griffiths R, Roland M, Hasan I, Powell Davies G, Harris M. Chronic disease management in primary care: From evidence to policy. Medical Journal of
Mitchell, G.K., Tieman, J.J. & Shelby-James, T.M. (2008). Multidisciplinary care planning and teamwork in primary care. MJA, 188(8), S61-S64.
Powell-Davies, G., Harris, M., Perkins, D., Roland, M., Williams, A., Larsen, K. & McDonald, J. (2006). Coordination of care within primary health care and with other sectors: A systematic review. Research Centre for Primary Health Care and Equity,
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