Multidisciplinary care planning and teamwork in primary care

Abstract

Objective: To examine policy and implementation issues around multidisciplinary care planning (MDP) as a means of improving outcomes for patients with chronic disease and/or complex care needs.

Methods: We conducted a series of five systematic reviews of the literature from 1990 to 2006, sampling a spectrum of issues associated with chronic disease and complex health care needs, with a focus on planning and provision of multidisciplinary care.

Results: Our review showed that MDP does improve many functional outcomes in the areas studied. Analysis of MDP programs involves examination of two groups of variables - the multidisciplinary components (a range of clinical perspectives and specialist knowledge) and team components (eg, communication and support). Implementing MDP requires changing patterns of interaction between care providers, alignment of roles and work practices, and changes to organisational arrangements.

Conclusion: While MDP improves many functional outcomes, widespread implementation of MDP in standard practice will require complex and targeted strategies. Devising and testing such strategies is a prerequisite for widespread, routine use of MPD in chronic disease management.