The multidisciplinary care (MDC) team should comprise the core disciplines integral to the provision of good care. Team membership will vary according to cancer type but should reflect both clinical and psychosocial aspects of care and the patient’s general practitioner. When considering the treatment and care of Aboriginal and Torres Strait Islander patients, it is essential that the team includes an expert in providing culturally appropriate care to this population.
The general practitioner (GP) may play a number of roles in all stages of the disease process, including diagnosis, referral, treatment, coordination, and continuity of care as well as provision of information and support to the patient and his/her family.
While it may not be possible for general practitioners to attend multidisciplinary care team meetings on a regular basis, it is essential that the GP is kept informed in a timely manner about treatment decisions.
Geographical remoteness and/or small size of the institution delivering care should not be impediments to the delivery of MDC nor to access to services. Systems should be established to support collaborative working links between team members. It is important that referral links with remote services are established and can be drawn upon as required.
An effective team approach to care ensures smooth transitions for the patient along the continuum of care. Changes to the team should be communicated to the patient and MDC team members at a time which is appropriate to all. Providing appropriate information to the patient will improve patient understanding about their disease and assist with continuity of care throughout the patient’s cancer journey.
Examples of team membership
Coordination of multidisciplinary care
The MDC team should designate an agreed point of contact. The agreed point of contact may be fulfilled by a nurse or other supportive care personnel. The team should consider who within their team can fulfil this role, if a designated person is not already in place. The role of this person will be to coordinate administrative aspects of the patient’s care, which may include:
- ensuring effective communication between team members, other health professionals and the patient and caregivers
- providing information and referral to services and programs to the patient and caregivers
- providing follow-up and support for the patient and caregivers
- providing written information and resources
A lead health professional may also be designated to liaise with the patient and their caregivers, where appropriate, regarding treatment and care planning.
"The MDC meeting certainly became much more efficient once the breast care nurse came in.”
Establishing a team identity
Practical examples of how to promote team identity may include
- developing a team name and agreed values that reflects the teams function
- establishing a communications framework to support the team and ensures participation from all relevant team members at regular and dedicated case conference meetings
- agreeing on the purpose of the meetings
- displaying posters identifying team members in public areas
- developing a team identifier such as a logo and letterhead (taking account of local protocols regarding the use of logos)
- providing regular team updates via email or a ‘bulletin board’ for team communication.
See also - Case study: establishing a team identity
A communications framework
A communications framework should be developed which encourages and supports input into case discussion from all relevant team members. The framework may vary depending on the type and size of service and should acknowledge diversity and flexibility in the way that case discussion is conducted. Seamless care involves effective and timely communication between all health professionals including the patient’s GP. For example, informing the patient’s GP about discussion and treatment outcomes prior to patient contact will ensure that the GP provides the patient with accurate, relevant and up-to-date information about their treatment and care.
Multidisciplinary care team meeting
Regular team meetings are an integral component of MDC. A central theme of meetings should be prospective treatment planning.
Once the team is established it may be appropriate to hold meetings outside the usual MDC treatment planning meetings to discuss specific topics of interest or for professional development. Using the meetings as an educational and information-sharing opportunity, as well as for treatment planning, can help both to encourage attendance and ensure sustained interest.
See also a recommended Multidisciplinary care meeting – attendance register form (DOC 40 KB).