Care coordination and the role of multi-disciplinary teams

Carrier, Judith ORCID: https://orcid.org/0000-0002-2657-2280, Jones, Anna ORCID: https://orcid.org/0000-0002-0742-8945 and Newbury, Gina 2022. Care coordination and the role of multi-disciplinary teams. Carrier, Judith, ed. Managing Long-term Conditions and Chronic Illness in Primary Care: A Guide to Good Practice. 3rd ed., Routledge, pp. 35-49.

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Abstract

Current policy emphasis continues to be on moving patients out of acute care settings and providing care in the community. For patients with long-term conditions (LTCs), it has long been accepted that care should be provided in the primary care/community setting with a firm emphasis on self-management. People with LTCs use disproportionately more primary and secondary care services, a pattern set to increase with an ageing population. This chapter explores principles behind case management/care coordination and disease-specific care management, including the importance of multi-disciplinary team (MDT) involvement. Existing nursing roles such as district nursing and general practice nursing in meeting the needs of people with LTCs are reviewed, in addition to new and existing nursing and health care professional roles in the primary care/community setting such as Advanced Practitioners. The term ‘case management’ originates from the USA, with its roots in social care, as a method of delivering holistic individualised care, tailored to the needs of people with complex health and social care problems with the term care coordination increasingly used. Disease-specific care management involves providing people who have a complex single need or multiple conditions with responsive, specialist services using multi-disciplinary teams and disease-specific protocols and pathways, including for example, NICE guidelines and the Quality and Outcomes Framework (QOF). The Year of Care partnerships promote personalised care and support planning for people with LTCs.

Item Type:	Book Section
Date Type:	Publication
Status:	Published
Schools:	Healthcare Sciences
Publisher:	Routledge
ISBN:	9780367897079
Last Modified:	04 Jun 2024 13:10
URI:	https://orca.cardiff.ac.uk/id/eprint/156235

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