Multidisciplinary care: experience of patients with complex needs Della Maneze A,C,E , Sarah Dennis A , Huei-Yang Chen A,B , Jane Taggart A , Sanjyot Vagholkar C , Jeremy Bunker C and Siaw Teng Liaw C,D A Centre for Primary Health Care and Equity, University of New South Wales, Sydney NSW 2052, Australia. B C-MARC, Curtin University, GPO Box U1987, Perth, WA 6845, Australia. C South Western Sydney Local Health District General Practice Unit, PO Box 5, Fairfield, NSW 1860, Australia. D School of Public Health and Community Medicine, University of New South Wales, NSW 2052, Australia. E Corresponding author. Email: della.maneze@sswahs.nsw.gov.au 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. Additional keywords: diabetes, inter-professional, multidisciplinary care, patient, self-management, socioeconomically disadvantaged. Received 1 June 2012, accepted 3 September 2012, published online 1 October 2012 Introduction The Chronic Care Model (CCM) describes six elements that are essential for improving the quality of care for patients with chronic disease (Wagner et al. 1996). It aims to create a system that cultivates informed and activated patients with a health care team that is proactive and prepared. A feature of the CCM that has been shown to be effective is delivery system design and the important role of the multi-disciplinary team in planned follow up to support self-management (Dennis et al. 2008) The Innovative Care for Chronic Conditions (ICCC) further expanded this to include the patient’s support networks, such as their family, with the aim of shifting the patient from being a passive recipient of care to being an active member of the care team (Epping-Jordan et al. 2004). The patient/family – health care team dyad central to the CCM model was further extended in the ICCC to include community partners providing an ideal seamless transition between hospital, home and community. This may involve supporting patients in gaining self-management skills, addressing broad needs affecting care, communicating with health professionals, adhering to follow up and monitoring treatment. As a result of this shift toward proactive management of chronic diseases across different levels of care, patients are increasingly interacting with several specialist health professionals. While integrated multidisciplinary management can provide optimal care for patients with chronic disease, implementation of this in practice has proven to be challenging (Harris et al. 2008). Concerns have been raised about continuity of care and the impact of this on the patients receiving care (Kirby et al. 2008). Under the Australian Medicare Team Care Arrangement (TCA) initiative, GPs may refer patients with chronic diseases to at least two allied health professionals for coordinated adjunctive care. TCA collaborations require two- way communication between service providers and regular Journal compilation Ó La Trobe University 2014 www.publish.csiro.au/journals/py CSIRO PUBLISHING Australian Journal of Primary Health, 2014, 20, 20–26 Research http://dx.doi.org/10.1071/PY12072