Multidisciplinary care planning and teamwork in primary care

Australia’s population is ageing. Estimates from the Australian Bureau of Statistics indicate that the proportion of Australians aged 65 years or over will increase from 13% in 2004 to between 26% and 28% in 2051.1 Furthermore, the number of the very old is also likely to increase, with people over 85 years of age expected to form 5% of Australia’s population by 2051.2

Statistical trends in disability suggest that these additional years of life in Australia are not necessarily disability-free years of life. Instead, a proportion of this increased time will be spent with light-to-moderate disabilities.3 People aged 65 years and over are more likely to have disabilities than younger people, and the likelihood of acquiring a disability increases with age. Severity of disability also increases as people get older.4

Chronic diseases presently make up more than 70% of Australia’s overall disease burden due to death, disability and diminished quality of life; this is expected to increase to 80% by 2020.5 These patterns are likely to increase the pressure on health care services and consequently on health expenditure. They are also likely to have specific burdens for primary care providers, who act as gatekeepers to health services and are often the point of coordination for the patient.

Interest in integration, coordination and multidisciplinary care approaches (Box 1) reflects a response to the emerging pattern of needs resulting from an ageing population and a changing pattern of disease. Potentially, they offer a means to moderate demands on the health system by managing health care needs through the primary care sector within the community setting and preventing, deferring or reducing the demands on the secondary and tertiary sectors.

Multidisciplinary care occurs when professionals from a range of disciplines work together to deliver comprehensive care that addresses as many of the patient’s health and other 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. From the individual patient’s point of view, this distinction is not critical — patients “see” care delivered in similar aliquots, and by a similar range of disciplines.

General practice also provides continuity of care for patients, and personalises the care that is offered. General practice provides day-to-day care of episodic and chronic conditions, as well as gatekeeping and coordination roles. In the context of chronic disease management, the complexity of care frequently requires other professionals to be involved. This may be professionals within the general practice setting, as well as outside of it. This reality is reflected in changes of definition — contrast the Royal Australian College of General Practitioners’ person-based definition of general practice of the 1970s11 with a later view that allows for a broader, team-based style of care, with its inherent risks of fragmentation of care.12

For primary care, participation in multidisciplinary teams may be initiated in the secondary sector or by primary care practitioners themselves to ensure comprehensive care for a patient. Uptake of care planning has accelerated in recent years,13 and examples of systematic implementation of multidisciplinary care are emerging.14

Here we examine some of the policy, operational and implementation issues associated with multidisciplinary team care planning. These include questions about who constitutes a multidisciplinary team; whether teams for a given condition are generated by primary or secondary care, and what motivates their formation; what features of the team or the way it works facilitate improved outcomes; and what policy changes might facilitate the uptake of multidisciplinary care planning (MDP).

We completed a systematic examination of integration, coordination and multidisciplinary approaches to the care of people with chronic or complex care needs, with primary care delivery as the focus. Given the vast literature on the subject, we opted to examine the impact of two examples of these care approaches — MDP and multidisciplinary team care — on a series of sentinel conditions that represented common trajectories of chronic illness10 and sentinel populations with complex care needs. The selected populations were palliative care patients and the frail aged. The disease trajectories represented were slow progression over years with rapid deterioration towards the end of life (type 2 diabetes mellitus); relapsing and remitting disease (chronic obstructive pulmonary disease [COPD]), and severe disease requiring high-level care on a daily basis (completed stroke). The result was a series of five systematic reviews sampling a spectrum of chronic and complex health care needs. The specific review questions for each of the five studies are detailed in Box 2.

The common aspect for each study population was that care was needed over a period of time and that the focus of care was not curative. The conduct of each systematic review was similar, and the methodology is briefly outlined in Box 3. Full details on the study methodology can be found elsewhere.18,19

There was diversity in outcome measures identified within and between the individual reviews. Literature that described care planning often did so in the context of complex care interventions, so it was difficult to assess the impact of care planning in isolation.

Specific issues from the individual reviews are briefly described here, and in more detail in a companion article.18 In early-stage diabetes, the review found that care planning and the subsequent care were normally based in the community and managed by general practice. The aim of care was to normalise glycaemic control and cardiovascular function and to detect potential complications. Physical outcomes were mixed, but all projects reported improvements in the process of care. There appeared to be a relationship between the diversity of the care team and improvements in outcomes.

In COPD, multidisciplinary team care was mostly managed from secondary care and delivered in the community. Contact with general practice varied in intensity and structure. Meaningful contact between general practices and the primary care team and specialist services at the time that care plans were developed appeared to be important. One form of care planning identified in the literature was the development and implementation of agreed treatment protocols. Across studies, lung capacity did not improve, but there was improved functional capacity and quality of life. Costs were increased, as was the use of certain services that appeared to result from increased patient understanding of the necessity to treat infective exacerbations early.

In completed stroke, multidisciplinary team management was almost completely hospital-led, with outreach into the community. Outcomes were the length of stay in hospital, the proportion of patients who were able to return to the community, and the proportion who were functionally independent. There were few randomised controlled trials, but they demonstrated improved outcomes where there was intense care planning and where a clear role delineation for the general practitioner was identified. Specialist expectations of the role of the GP did not necessarily match what actually happened, highlighting the importance of defining the tasks allocated to the GP.

For palliative care, communication between GPs and specialist palliative care services was particularly important. Case conferences seemed to be a logical means of providing that care planning and delivery, and there were benefits for the participants. Many of these related to in-depth dialogue about the patient and opportunities for learning and debriefing for difficult cases. However, utilisation of the Enhanced Primary Care (EPC)9 item for case conferences remains relatively low.20 Barriers to uptake identified in the review included organisational barriers and legislative and remuneration requirements, such as complex paperwork, workload issues and time constraints. As seen in the COPD review, care coordination resulted in increased costs and use of services.