Multidisciplinary teams

What are MDTs and why are they important to integration?

Multidisciplinary teams (MDTs) are the mechanism for organising and coordinating health and care services to meet the needs of individuals with complex care needs.

The teams bring together the expertise and skills of different professionals to assess, plan and manage care jointly. Based in the community, and networked with primary care, MDTs are expected to work proactively to support individuals’ care goals.

Through accessing a range of health, social care and other community services, MDTs focus on keeping people well and independent, delivering the right care at home or in the community to prevent unnecessary hospital care.

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How do MDTs support integration?

MDTs consist of practitioners and professionals from health, care and allied disciplines and sectors that work together to provide holistic, person-centred and coordinated care and support.

The composition of MDTs varies depending on delivery models and settings but it may include: GPs, specialist doctors, nurses, physiotherapists, occupational therapists, pharmacists, social workers and, increasingly, representatives of the housing and voluntary sectors. MDTs also often include link workers or care navigators, who can support social prescribing by connecting individuals with local groups and community support services.

A holistic and integrated approach to care and support requires the coordination of multiple interventions and services, built around the complex continuum of people’s needs, personal strengths and desirable outcomes.

MDTs play an important role, bridging professional boundaries and breaking down the barriers of competing cultural and organisational differences. When successful, they enable comprehensive, continuous and seamless care services to be delivered.

Led by a nominated care coordinator or lead, MDTs can ensure significant benefits for service users:

  • joint assessments and care planning, informed by service users’ own goals and decisions
  • better communication and information-sharing across the team and with the service user
  • greater involvement of the service user, or their carers, in decisions about care
  • a single point of access through a key worker or named coordinator
  • rapid access to specialist expertise in the community, including urgent care in a crisis and at transitions of care (e.g. hospital discharge)
  • access to a range of community services that support wellbeing, self-management and prevention (e.g. falls prevention services or home adaptations

Which service users will benefit from an MDT’s care coordination?

Research evidence indicates that integrated care, and MDTs in particular, are especially suitable for people with complex needs and long term-conditions, who benefit most from a holistic provision of care.

MDTs and inter-professional collaboration is a flexible and adaptable approach, shown to be effective for a whole range of populations, including older people, children and people with mental health problems.

What support and conditions do MDTs need to fulfil their role?

For MDTs to succeed with care coordination and management, a number of enablers and contextual factors need to be in place. The evidence indicates that these include:

  • trusting relationships within the team
  • a shared vision of integrated care and clear goals
  • strong system and team leadership, accompanied by consistent working practices and protocols
  • good access to shared resources across partner organisations
  • a broad range of community-based services from which to provide proactive care management
  • opportunities for informal communication and reflective team learning
  • dedicated case managers taking responsibility for individual service users
  • shared access to the care records of service users
  • specific training and professional development, especially joint training within the team
  • a good mix of professional backgrounds and boundary-spanning roles, and
  • involvement of service users or their carers in care planning and decision-making.

What is the evidence for outcomes and impact?

The evidence suggests that MDT approaches are associated with improved outcomes for people who use services, including:

  • better treatment planning and compliance
  • more services provided at home or close to home
  • reduction in service utilisation (hospital admission, A&E attendance, readmission and length of stay)
  • greater self-management and better preventative care to stay well
  • improved service user experience
  • people’s engagement and activation through social prescribing and shared decision-making
  • greater continuity of care across different care settings.