Establish multidisciplinary teams composed of professionals with the most relevant expertise, supported by efficient ways of working, clear accountabilities, and robust management systems to effectively manage caseloads across the system.
The primary focus of High Impact Change Model: reducing preventable admissions is to reduce admissions to hospitals by remaining in or returning to the community.
C1: MDT with membership drawn from clinicians and professionals with the most relevant skills and experience in the system
- Neighbourhood MDTs can support preventative interventions with high risk individuals (see High Impact Change 2) as well as support people to stabilise after a recent crisis event.
- Determine the attendees based on the cohorts being supported and the necessary skills and inputs required. A list of potential MDT members is included in the Suggested Actions section below.
- Balance who attends formal MDT meetings versus those available for specific input to avoid inefficiency. Ensure staff are equipped with the right tools to help them and the people they support find and make contact with the right services e.g. up-to-date local directories and decision support tools.
C2: MDT ways of working which are effective and efficient in supporting the MDT caseload
- Focus on using proactive case management approaches and support to provide home-based care rather than secondary care. Practical elements of MDT working are discussed in the Suggested Actions section below.
- Use trusted assessment principles to carry out a holistic assessment of need, avoid duplication and reduce the time someone waits to be assessed. This can be undertaken by the best-placed person who is involved in the person’s care, for example social worker, community physiotherapist or crisis response team. Ensure people and their family and/or carers are involved in, and share, the decision-making.
- Ensure data sharing enables efficient working and for teams to work from a shared version of the truth re. their caseload.
C3: Effective management systems and clear accountabilities
- Clarify roles and commitments while fostering a collaborative team culture, catering to the different organisational affiliations and responsibilities outside the MDT.
- Secure time commitments and ensure organisations plan and budget for staff participation in MDT working. This may require system finance discussions where costs incurred sit separately to the value in terms of reduced activity elsewhere.
- Communicate the significance of the Neighbourhood MDT's goals, ensuring they align with organisational targets and priorities.