MDT_01EngagingMultidisciplinary Team Approaches
Proactively Identify High-Need Patients for MDT Care Planning
Summary
Use structured methods (e.g., SNOMED coding, deprivation indexes) to proactively identify Focus Patients who would benefit most from multidisciplinary care planning and implement MDT-led interventions.
Supporting information
Multidisciplinary team working is most effective when practices proactively identify and prioritise a sub-set of Focus Patients who have multiple intersecting needs. Patients with complex health and social needs often struggle with fragmented care across multiple services. Proactive identification ensures those who would most benefit from coordinated care receive it.
Approaches to implementation:
- Develop clear criteria combining clinical, social, and engagement factors
- Use practice searches to identify patients meeting multiple complexity indicators
- Include staff insights about patients struggling with current care arrangements
- Prioritise patients where coordinated care could prevent crisis or admission
- Ensure identification process captures Focus Patients who may be less visible
Key benefits: Prevents complex patients from falling through gaps between services, reduces crisis presentations through proactive coordination, and ensures MDT resources are allocated based on need rather than demand.