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The RACGP Curriculum for Australian General Practice 2011



Multidisciplinary care

Definition

Multidisciplinary care occurs when professionals from a range of disciplines with different but complementary skills, knowledge and experience work together to deliver comprehensive healthcare aimed at providing the best possible outcome for the physical and psychosocial needs of a patient and their carers. As patient needs may change with time, the composition of the team may also change to meet these needs.1

A strong culture of multidisciplinary care is seen as critical to improving the primary healthcare of Australia.2

Curriculum in practice

The following case illustrates how the multidisciplinary care curriculum applies to general practice:

  • Mick, 37 years of age, is an Aboriginal man who was diagnosed with diabetes at age 16 years. His urinalysis reveals 3+ proteinuria, his vision is poor and he has peripheral neuropathy along with an ulcerated rash of his lower legs. Morbidly obese, his sugar levels have seldom been recorded at less than 30 and yet he has refused all treatment on the basis that, 'Diabetes means I'm going to die anyway so what's the point?' He presents following the death of his sister, who had been on dialysis for several years for diabetic nephropathy. As he is now the carer for his nephew he is motivated to take more care of his health and wants your assistance.

Rationale and general practice context

While multidisciplinary care provides a more diverse range of skills and experience than a single health professional does, co-ordination and continuity of care, and clinical team leadership is a primary function of the general practitioner,1 3 even though primary care participation in multidisciplinary teams may be initiated outside the general practice setting.1

Successful multidisciplinary care requires GPs to be able to build continuous, close and respectful therapeutic relationships with patients to deliver accessible, integrated patient care. This involves leading, supporting and co-ordinating flexibly configured clinical teams and engaging with diverse specialists and other sector services according to individual patient or family needs. In addition, the GP is increasingly the custodian of, and conduit for, key patient clinical information.3

While multidisciplinary teams enable a more comprehensive approach to meeting the comprehensive needs of individual patients, GPs still need to be able to provide day-to-day care of episodic and chronic conditions.1

The role of the general practitioner in multidisciplinary care

The rise of care planning in many areas of chronic disease has resulted in an increasing role of GPs in multidisciplinary care.4 Team based care in primary care clinical areas such as diabetes, aged care, mental health and disability have led to the emergence of systematic approaches of team based care, both within and outside of practices1 as reflected in the role of co-ordinated and comprehensive care in the recently revised RACGP definition of general practice:

'General practice provides person centred, continuing, comprehensive and co-ordinated wholeperson healthcare to individuals and families in their communities'.3

General practitioners need to operate within teams across diverse clinical settings such as between primary healthcare services and hospital based and or practice based clinicians to provide comprehensive team based care. This implies differences in governance structure and funding models. However, GPs have a gatekeeping role within the multidisciplinary care team.

Key GP skills for working within multidisciplinary settings include:

  • identifying multidisciplinary team members and how they function especially when working with complex health needs and differing environments
  • clear communication and interaction between team members
  • mutual respect, trust and inclusiveness between team members
  • the best use of the skill mix within the team
  • good clinical governance.

General practitioners need to be able to work to overcome common barriers to multidisciplinary care such as:8

  • time constraints
  • lack of systems that promote teamwork including financing and infrastructure
  • fragmentation due to a predominantly part time workforce
  • lack of understanding about how teams function
  • professional issues such as individual accountability

General practice needs to be well organised to implement effective team based management of chronic disease9 requiring clinical leadership on the part of the GP.8

Related curriculum areas

Refer also to the curriculum statements:

Training Outcome of the five domains of general practice

1. Communication skills and the patient-doctor relationship

MDCT1.1

Negotiate common ground with patients about their problems and expectations from team based care.

MDCT1.2

Negotiate an effective management plan with patients including defining respective responsibilities and limits with the patient, family and carers.

MDCT1.3

Communicate clearly and clarify the various roles and responsibilities of the multidisciplinary care team members with the patient, family and carers.

MDCT1.4

Discuss the patient's understanding of the problem, management, advice and follow up within the multidisciplinary team setting.

2. Applied professional knowledge and skills

MDCT2.1

Negotiate, prioritise and implement patient management within the multidisciplinary setting.

MDCT2.2

Be able to co-ordinate care within multidisciplinary teams.

MDCT2.3

Understand the role and functioning of multidisciplinary care especially within the context of chronic disease or complex health needs.

MDCT2.4

Define the members of a multidisciplinary team for individual patients and their skills, roles and responsibilities and how they function.

MDCT2.5

Identify and use hospital and community based expertise, resources and networks effectively.

MDCT2.6

Recognise opportunities for health promotion and education and respond appropriately to increase the patient's capacity for self care within the multidisciplinary setting.

MDCT2.7

Make appropriate and timely decisions about referral and follow up.

3. Population health and the context of general practice

MDCT3.1

Understand the role of the GP in multidisciplinary care in the Australian health system (including care planning, services funding, policies and community resources).

MDCT3.2

Recognise and respond to how a patient's cultural and linguistic diversity and their relationships with family and significant others may impact upon interactions with multidisciplinary healthcare providers outside of the general practice setting.

MDCT3.3

Incorporate cultural and linguistic diversity into general practice multidisciplinary management.

MDCT3.4

Know the availability of local, regional and national multidisciplinary care services.

4. Professional and ethical role

MDCT4.1

Understand the GP's role within the multidisciplinary team.

MDCT4.2

Practice and promote respect, trust and inclusiveness between multidisciplinary care team members.

MDCT4.3

Understand the gatekeeper role of GPs in multidisciplinary team care.

MDCT4.4

Act as a patient advocate appropriate within the multidisciplinary setting.

MDCT4.5

Describe the accountability of GPs within multidisciplinary care.

MDCT4.6

Apply clinical leadership skills appropriately within the multidisciplinary team.

MDCT4.7

Show respect for a patient's culture and values, and an awareness of how these impact on the therapeutic relationship within general practice multidisciplinary care.

MDCT4.8

Respect patient informed consent and privacy when working with other members of a multidisciplinary team.

5. Organisational and legal dimensions

MDCT5.1

Communicate and interact clearly with all members of the general practice multidisciplinary team.

MDCT5.2

Understand the role of practice systems in providing clear communication with all practice members.

MDCT5.3

Understand the accountability of all of the members of a multidisciplinary team.

MDCT5.4

Use time management skills during multidisciplinary team care.

MDCT5.5

Understand the importance of open, supportive environments for open discussion with multidisciplinary team members to promote quality care.

MDCT5.6

Understand the role of clinical governance in multidisciplinary care in the general practice setting and how this may interact with other organisations' governance.

MDCT5.7

Understand the role of general practice medical records in co-ordinating clinical care within a multidisciplinary setting including the role of practice information management and data systems relating to: clinical standards, guidelines and protocols; medical records; information technology; communication and transfer of patient-related information; screening, recall and related systems; and access and confidentiality.

MDCT5.8

Evaluate practice management skills relating to patient access guidelines; staff management; teamwork; office policies and procedures; financial and resource management.

MDCT5.9

Incorporate medicolegal knowledge and responsibilities relating to multidisciplinary care with respect to: certification; confidentiality; legal report writing; prescribing; informed consent; duty of care; litigation.

MDCT5.10

Use effective time management skills in multidisciplinary care.

Learning objectives across the GP professional life

Medical student

1. Communication skills and patient-doctor relationship

MDCLM1.1

Discuss the importance of negotiating common ground with patients about their problems and expectations from team based care in multidisciplinary care.

MDCLM1.2

Outline the structure of effective multidisciplinary management plans with patients including defining respective responsibilities and limits with the patient, family and carers.

MDCLM1.3

Outline the need for communicating clearly and clarifying the various roles and responsibilities of the multidisciplinary care team members with the patient, family and carers.

MDCLM1.4

Outline issues affecting the patient's understanding of the problem, management, advice and follow up during multidisciplinary care.

2. Applied professional knowledge and skills

MDCLM2.1

Describe the key features of multidisciplinary care.

MDCLM2.2

Compare multidisciplinary care to care with a single healthcare provider.

MDCLM2.3

Describe how to negotiate, prioritise and implement patient multidisciplinary care.

MDCLM2.4

Describe the range of members of a multidisciplinary team and outline their skills, roles and responsibilities.

MDCLM2.5

Outline how to make appropriate and timely decisions about referral and follow up.

3. Population health and the context of general practice

MDCLM3.1

Describe multidisciplinary care within the Australian health system including the role of the GP.

MDCLM3.2

Describe the impact of cultural and linguistic diversity on multidisciplinary care.

4. Professional and ethical role

MDCLM4.1

Outline professional responsibilities within a multidisciplinary team including lines of accountability.

MDCLM4.2

Describe the importance of respect, trust and inclusiveness for multidisciplinary care team members.

MDCLM4.3

Discuss the need for respecting a patient's culture and values within the therapeutic relationship within multidisciplinary care.

MDCLM4.4

Describe the role of patient informed consent and privacy when releasing patient information to other members of a multidisciplinary team.

5. Organisational and legal dimensions

MDCLM5.1

Outline the importance of clear communication lines with all members of the multidisciplinary care team.

MDCLM5.2

Describe the role of systems in providing clear communication with all members of a multidisciplinary team.

MDCLM5.3

Describe the need for open discussion with multidisciplinary team members to promote quality care.

MDCLM5.4

Outline the role of medical records in co-ordinating clinical care.

MDCLM5.5

Outline the need for accurate and legible recordings of consultations and referrals, to enable continuity of care.

Prevocational doctor

1. Communication skills and patient-doctor relationship

MDCLP1.1

Demonstrate the ability to negotiate common ground with patients about their problems and expectations from team based care in multidisciplinary care.

MDCLP1.2

Make effective management plans with patients including defining respective responsibilities and limits with the patient, family and carers.

MDCLP1.3

Demonstrate how to communicate clearly and clarify the various roles and responsibilities of the multidisciplinary care team members with the patient, family and carers.

MDCLP1.4

Discuss the patient's understanding of the problem, management, advice and follow up during multidisciplinary care.

2. Applied professional knowledge and skills

MDCLP2.1

Demonstrate the ability to negotiate, prioritise and implement patient multidisciplinary care.

MDCLP2.2

Describe the role and functioning of multidisciplinary care.

MDCLP2.3

List the members of a multidisciplinary team for individual patients and outline the skills, roles and responsibilities of each member and their functions.

MDCLP2.4

Demonstrate ability to make appropriate and timely decisions about referral and follow up.

3. Population health and the context of general practice

MDCLP3.1

Outline the role of the GP in multidisciplinary care in the Australian health system.

MDCLP3.2

Outline the special issues in multidisciplinary healthcare when working with patients from culturally and linguistically diverse backgrounds, including the impact on their relationships with family and significant others.

4. Professional and ethical role

MDCLP4.1

Describe the prevocational doctor's roles and responsibilities within the multidisciplinary team.

MDCLP4.2

Demonstrate respect, trust and inclusiveness for multidisciplinary care team members include those in general practice.

MDCLP4.3

Demonstrate respect for a patient's culture and values, and an awareness of how these impact on the therapeutic relationship within multidisciplinary care.

MDCLP4.4

Describe the role of patient informed consent and privacy when releasing patient information to other members of a multidisciplinary team.

5. Organisational and legal dimensions

MDCLP5.1

Communicate and interact clearly with all members of the multidisciplinary team including with general practice.

MDCLP5.2

Describe the role of organisational systems in providing clear communication with all members of a multidisciplinary team.

MDCLP5.3

Outline the importance of open, supportive environments for open discussion with multidisciplinary team members to promote quality care.

MDCLP5.4

Outline the role of medical records in co-ordinating clinical care within a multidisciplinary setting.

MDCLP5.5

Make accurate and legible recordings of consultations and referrals, to enable continuity of care.

Vocational registrar

1. Communication skills and patient-doctor relationship

MDCLV1.1

Demonstrate the ability to negotiate common ground with patients about their problems and expectations from team based care in the general practice setting.

MDCLV1.2

Make effective general practice management plans with patients including defining respective responsibilities and limits with the patient, family and carers.

MDCLV1.3

Demonstrate how to communicate clearly and clarify the various roles and responsibilities of the multidisciplinary care team members with the patient, family and carers in the general practice setting.

MDCLV1.4

Discuss the patient's understanding of the problem, management, advice and follow up during multidisciplinary care in the general practice setting.

2. Applied professional knowledge and skills

MDCLV2.1

Demonstrate the ability to negotiate, prioritise and implement patient multidisciplinary care within the general practice setting.

MDCLV2.2

Demonstrate how to co-ordinate care within multidisciplinary teams.

MDCLV2.3

Describe the role and functioning of multidisciplinary care especially within the context of chronic disease or complex health needs and how this may change over time.

MDCLV2.4

List the members of a multidisciplinary team for individual patients and outline the skills, roles and responsibilities of each member and how they function in the general practice setting.

MDCLV2.5

Identify and use hospital and community based expertise, resources and networks effectively.

MDCLV2.6

Describe how to use opportunities for health promotion and education and their multidisciplinary management within the general practice setting.

MDCLV2.7

Demonstrate the ability to make appropriate and timely decisions about referral and follow up.

3. Population health and the context of general practice

MDCLV3.1

Describe the role of the GP in multidisciplinary care in the Australian health system including care planning, services funding, policies and community resources.

MDCLV3.2

Outline the management of referrals and interactions with multidisciplinary healthcare providers outside of the general practice setting with patients from culturally and linguistically diverse backgrounds, including the impact on their relationships with family and significant others.

MDCLV3.3

Outline the availability of local, regional and national multidisciplinary care services.

4. Professional and ethical role

MDCLV4.1

Describe the roles and responsibilities of the GP within the multidisciplinary team including the role as patient advocate, a leader, and co-ordinator of care.

MDCLV4.2

Demonstrate respect, trust and inclusiveness for multidisciplinary care team members.

MDCLV4.3

Describe the gatekeeper role of GPs in multidisciplinary care team.

MDCLV4.4

Demonstrate respect for a patient's culture and values, and an awareness of how these impact on the therapeutic relationship within general practice multidisciplinary care.

MDCLV4.5

Describe the role of patient informed consent and privacy when working with other members of a multidisciplinary team.

5. Organisational and legal dimensions

MDCLV5.1

Communicate and interact clearly with all members of the general practice multidisciplinary team.

MDCLV5.2

Describe the role of practice systems in providing clear communication with all practice members.

MDCLV5.3

Demonstrate effective time management skills during multidisciplinary team care.

MDCLV5.4

Outline the importance of open, supportive environments for open discussion with multidisciplinary team members to promote quality care in the general practice setting.

MDCLV5.5

Describe the role of clinical governance in multidisciplinary care in the general practice setting and how this may interact with other organisations' governance.

MDCLV5.6

Outline the role of general practice medical records in co-ordinating clinical care within a multidisciplinary setting including the role of practice information management and data systems relating to: clinical standards, guidelines and protocols; medical records; information technology; communication and transfer of patient-related information; screening, recall and related systems; and access and confidentiality.

MDCLV5.7

Describe the processes for evaluating practice management skills relating to patient access guidelines; staff management; teamwork; office policies and procedures; financial and resource management.

MDCLV5.8

Outline the medicolegal knowledge and responsibilities relating to multidisciplinary care with respect to: certification; confidentiality; legal report writing; prescribing; informed consent; duty of care; litigation.

MDCLV5.9

Make accurate and legible recordings of consultations and referrals, to enable continuity of care by GPs and other colleagues involved.

Continuing professional development

1. Communication skills and patient-doctor relationship

MDCLC1.1

Demonstrate the ability to adapt communication skills to evolving multidisciplinary care structures that occur as a patient's needs evolve over time.

MDCLC1.2

Demonstrate the ability to review and refine effective general practice management plans with patients including defining respective responsibilities and limits with the patient, family and carers.

2. Applied professional knowledge and skills

MDCLC2.1

Demonstrate the ability to negotiate, prioritise and implement patient multidisciplinary care within the general practice setting as a patient's needs evolve over time.

MDCLC2.2

Demonstrate how to co-ordinate care within evolving multidisciplinary teams.

MDCLC2.3

Describe building links and relationships between the general practice and hospital and community based expertise, resources and networks.

MDCLC2.4

Demonstrate the use of opportunities for health promotion and education and their multidisciplinary management within the general practice setting.

3. Population health and the context of general practice

MDCLC3.1

Incorporate Australian health system multidisciplinary programs and policies into the general practice setting including care planning, services funding, and community resources.

MDCLC3.2

Demonstrate the management of referrals and interactions with multidisciplinary healthcare providers outside of the general practice setting with patients from culturally and linguistically diverse backgrounds, including the impact on their relationships with family and significant others.

4. Professional and ethical role

MDCLC4.1

Demonstrate meeting the GP's roles and responsibilities within the multidisciplinary team including the role as patient advocate, and leader and co-ordinator of care.

MDCLC4.2

Demonstrate the incorporation of patient informed consent and privacy into multidisciplinary care.

5. Organisational and legal dimensions

MDCLC5.1

Apply practice systems to the provision of clear communication with all practice members.

MDCLC5.2

Demonstrate effective time management skills during multidisciplinary team care.

MDCLC5.3

Describe how open discussion is promoted with multidisciplinary team members to promote quality care within the general practice setting.

MDCLC5.4

Demonstrate clinical governance measures in place for multidisciplinary care in the general practice setting.

MDCLC5.5

Describe the practice's medical record policies and procedures in place to co-ordinate clinical care within a multidisciplinary setting including the role of practice information management and data systems relating to: clinical standards, guidelines and protocols; medical records; information technology; communication and transfer of patient related information; screening, recall and related systems; and access and confidentiality.

MDCLC5.6

Demonstrate processes for evaluating practice management skills relating to patient access guidelines; staff management; teamwork; office policies and procedures; financial and resource management.

References

  1. Mitchell GK, Tieman JJ, Shelby-James TM. Multidisciplinary care planning and teamwork in primary care. Med J Aust 2008;188(8 Suppl):S61–4.
  2. Department of Health and Ageing. Primary health care teform in Australia. Report to support Australia's First National Primary Health Care Strategy. 2009. Available at www.yourhealth.gov.au/internet/yourhealth/publishing.nsf/Content/nphc-draftreportsupp-toc/$FILE/NPHC-supp.pdf.
  3. The Royal Australian College of General Practitioners. Definition of general practice. 2011. Available at www.racgp.org.au/whatisgeneralpractice.
  4. Harris MF, Jayasinghe UW, Taggart JR, et al. Multidisciplinary Team Care Arrangements in the management of patients with chronic disease in Australian general practice. Med J Aust;194(5):236–9.
  5. Zwar NA, Hermiz O, Comino EJ, Shortus T, Burns J, Harris M. Do multidisciplinary care plans result in better care for patients with type 2 diabetes? Aust Fam Physician 2007;36(1-2):85–9.
  6. Fuller JD, Perkins D, Parker S, et al. Building effective service linkages in primary mental health care: a narrative review part 2. BMC Health Serv Res 2011;11:66.
  7. Cancer Australia. Multidisciplinary care. Review of cancer control activities in Australia. Available at http://canceraustralia.gov.au/publications-resources/cancer-control-plans-and-reports.
  8. Taggart J, Schwartz A, Harris MF, et al. Facilitating teamwork in general practice: moving from theory to practice. Australian Journal of Primary Health 2009;15(1):24–8.
  9. Harris MF, Chan BC, Daniel C, Wan Q, Zwar N, Davies GP. Development and early experience from an intervention to facilitate teamwork between general practices and allied health providers: the Team-link study. BMC Health Serv Res10:104.

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