Theme 2. Healthy relationships, healthy teams
Through the application of a multidisciplinary approach, learn how we implemented the chronic disease management and prevention framework to adapt the principles of the ICCP into a plan to help improve at risk patient’s co-ordination of care and improve continuity of care. We will illustrate how we have been able to improve first contact, and intervene before issues arise. The inclusion of client appropriate allied health has helped to stream line the intervention so that it is designed to meet the needs of the individual client, and address any unmet social/mental health needs arising from or exacerbated by illness.
Our FHT initiated the Multi-D appointment approach to utilize the key concepts of the ICCP, but in a more efficient manner with a broader criterion including psychosocial issues. Sullivan et al (2016) suggest that building successful professional teams includes “re-envisioning goals, promoting shared decision making, communicating effectively and interprofessionally, clarifying roles, learning from failure, and using organizational structures to support multidisciplinary teams.” Our process is to encourage staff to use their professional judgement in initiating a referral for any “at risk” patient who might benefit from this contact. This maximizes the coordination and comprehensiveness of care by meeting together with the patient, their significant others, and the involved primary care providers. Our vision is to improve health outcomes and the self-efficacy necessary to manage chronic or acute conditions. We are striving to promote a culture of client centered, safe, multidisciplinary care. “Even in the best healthcare systems, patients most remember their individual encounters. We must ensure that the teams we create sustain our common goal of providing high-value care for every patient, every time (Handel, 2016).