About this action

Focus Patients with complex needs benefit most from continuity but often receive fragmented care. Small, dedicated multidisciplinary teams - sometimes known as microteams - working with defined caseloads can provide the consistent, coordinated care these patients need to. Approaches to implementation: - Use clinical judgement and data to Identify patients who would most benefit Form small MDTs with protected time for discussion and coordination of care Include diverse professionals based on patient needs Schedule regular team meetings to discuss all patients Create shared care plans accessible to all team members Monitor patient outcomes and experience of continuity Share learning about effective team models Key benefits: Provides genuine continuity and coordination for patients with complex needs, reducing crisis admissions and improving both clinical outcomes and patient experience.