Multidisciplinary care: experience of patients with complex needs

Abstract

Abstract. The rapidly increasing prevalence of diabetes with its high morbidity and mortality raises the need for an integrated multidisciplinary service from health care providers across health sectors. The aim of this study was to explore the diabetic patients' experience of multidisciplinary care, in particular their perceptions, perceived barriers and facilitators. Thirteen patients with type-2 diabetes admitted to the emergency department of a local hospital in NSW were interviewed and completed a demographic questionnaire. Results showed that patients found it inconvenient to be referred to many health professionals because of multiple physical and psychosocial barriers. Separate sets of instructions from different health professionals were overwhelming, confusing and conflicting. Lack of a dedicated coordinator of care, follow up and support for self-management from health professionals were factors that contributed to patients' challenges in being actively involved in their care. The presence of multiple co-morbidities made it more difficult for patients to juggle priorities and 'commitments' to many health professionals. In addition, complex socioeconomic and cultural issues, such as financial difficulties, lack of transport and language barriers, intensified the challenge for these patients to navigate the health system independently. Few patients felt that having many health professionals involved in their care improved their diabetes control. Communication among the multidisciplinary care team was fragmented and had a negative effect on the coordination of care. The patients' perspective is important to identify the problems they experience and to formulate strategies for improving multidisciplinary care for patients with diabetes.

Theory that explains an Aboriginal perspective of learning to understand and manage diabetes

“…[7][8][9] This would indicate that both an adjustment to the normative model and an improvement in the consistent application of the model is required. Other barriers to accessing primary care include cost, lack of transport and expensive medications and treatments 8,22,23 and this was also raised in our study.…”

“…There were several issues in common between our participants and other population groups such as experiences with fragmented care, 22,23 different understandings of disease between the patient and the health professional [22][23][24] and experiences of poor communication. 25 The health system response to these issues has been to develop models of care 4,26 on the premise that optimal diabetes management results from regular monitoring, setting and achieving clinical targets 6 supported by service-wide clinical audits.…”

Predictive Factors of Effects of an Interdisciplinary Chronic Disease Prevention and Management Intervention in Primary Healthcare: A Correlational Analysis

“…Moreover, results showed that professionals working in a cohesive manner on the same risk factors was associated with improvement in the Health Services Navigation domain. As identified by other authors, disorganized and fragmented services constituted barriers for patients, such as confusion and feelings of being overwhelmed by the process [42]. Findings emphasize the importance of cohesive multidisciplinary teams in CDPM, showing that professionals working together offer coordinated care with direct improvement in the way patients perceive the healthcare delivery system and in communication of their needs to the provider.…”

An “integrated health neighbourhood” framework to optimise the use of EHR data

“…The long-suffering patient has to deal with fragmented roles and responsibilities compounded by poor communication, fragmented programs and services. This fragmentation extends across interfaces for care, information provision, identification and handover, guidelines use and standards, access to their own records and privacy compliance 4 , 5. Fragmentation leads to poor and unsafe care and inappropriate use of emergency and hospital services, which are often preventable.…”

“…Fragmentation leads to poor and unsafe care and inappropriate use of emergency and hospital services, which are often preventable. Continuity and coordination of patient-centred care requires effective communication, coordination, teamwork and judicious use of information and communication technology4 , 5 within a medical home6 and across the health neighbourhood 7 , 8. This requires the effective use of electronic health records (EHRs), personal health records and electronic decision support tools to collect, share and use good quality information to provide safe, effective and coordinated care along ‘patient journeys’ and ‘care pathways’ in the health and social care system.…”