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Multidisciplinary Teams in Focus: Improving the Journey of the Person with Complex Needs

Project Added:
4 May 2015
Last updated:
21 April 2021

Multidisciplinary Teams in Focus: Improving the Journey of the Person with Complex Needs


This project aims to enhance multidisciplinary teamwork in a rural hospital, by ensuring that acute ward and community health staff participate in care planning for admitted patients and improve the interface between the acute settings and community health services.


To minimise hospitalisation and re-presentation rates of complex and older people and improve their health outcomes.


  • Improve management of people with complex health needs.
  • Reduce unplanned re-admissions of patients of a rural hospital.
  • Improve communication and continuity of care between service streams within the health service.

Project Status

Project status: Implementation - the initiative is currently being implemented.

Project dates: October 2014 to March 2015.


In November 2013, a review of community health services was undertaken to achieve alignment of services to the objectives of NSW Health.  The findings indicated a need for an integrated service delivery model between community health services and the acute ward, to address the high rates of avoidable admissions and unplanned re-admissions within 28 days.


  • A file audit of 28-day re-admissions to Deniliquin Health Service for the months of July and August 2014 demonstrated gaps in the care planning process.
  • Two multidisciplinary workshops were held in September 2014, including a broad cross-section of acute and community health clinicians from the Emergency Department (ED), Aged Care Assessment Team (ACAT), Transitional Aged Care Service (TRAC), Community Nursing and Allied Health
    • session 1 looked at the high rate of avoidable admissions and re-admissions within 28 days. The group completed a diagnostics session and analysed potential barriers to implementing changes required to address the high rate of re-admission.
    • session 2 presented the feedback from the first session, with further discussions around service priorities and possible solutions.
  • As a result of these workshops, there was an agreement to streamline admission and discharge processes, using resources available across the continuum, including ED , acute and community services.  Staff acknowledged the need to improve team members’ understanding of individual roles and communications between the acute and community settings, as well as improve knowledge of other service providers and how they may be accessed.
  • The policy Care Coordination: Planning from Admission to Transfer of Care in NSW Public Hospitals (PD2011_015)1 was presented as a resource to guide team meetings on the acute ward.
  • Daily multidisciplinary team meetings were introduced in September 2014. Multidisciplinary participation in transfer of care (or discharge) planning processes is central to optimal care planning and follow-up for people with complex conditions admitted to the acute ward or presenting to ED .


  • Clinical Excellence Commission, Clinical Leadership Program.

Implementation Site

  • Deniliquin Health Service, Murrumbidgee Local Health District (MLHD)


  • 28-day re-admissions are continuously monitored and reported monthly through the standardised operational reporting framework.
  • In March 2015, results indicated a reduction in 28-day re-admission rates from 8.7% at the beginning of the project to 4.5% (target 6.5%) since project activities commenced.
  • A repeat file audit in January 2015 showed there is further work required to implement policy PD2011_015.  Specifically, staff require training in the planning process and development of goals for the patient’s admission. Results of this will be measured by the number of completed care plans and identified discharge dates on audit.

Lessons Learnt

  • The proposed changes will take more time to fully execute than the project timeframe permitted.
  • In a rural context, local leadership is critical to success, especially when project team members are not co-located.
  • The introduction of electronic medical records (eMR) to the site coincided with the project implementation and allowed community health staff to access admitted patient details.  Access to technology may be a key factor in determining the next site to undergo a similar review.
  • The importance of a sustained focus in targeting the correct procedural changes, in order to achieve the desired outcome, was an important insight gained from the project.
  • A future project is under consideration, to provide staff training on the implementation of policy PD2011_015, which will focus on the finer elements of the transfer-of-care risk assessment.  This level of detail and focus was not envisaged at the outset, and was only possible as further information was collated during the project.
  • The complexity of services provided by the community health team, including outreach services covering a large geographical area, were significant issues that required discussion with staff.  This will be important to consider when commencing implementation at other sites in the region, as each site will have different issues to address.
  • Clinicians have a good understanding of the pressures that changes in service priorities are likely to create, particularly in view of community expectations.  They were explicit in their requirement for clear direction and guidance in setting new service priorities.
  • National health, aged care and disability reforms have significant influence on community health services, which are at the interface between acute care and primary health settings.


  1. NSW Ministry of Health. 2011. Care Coordination: Planning from Admission to Transfer of Care in NSW Public Hospitals (PD2011_015).  Sydney, NSW.

Further Reading

  1. Agency for Clinical Innovation. 2014. Risk Stratification: A discussion paper for NSW Health’s approach to Risk Stratification.
  2. Agency for Clinical Innovation. 2014. Building Partnerships: A Framework for Integrating Care for Older People with Complex Health Needs.
  3. Murrumbidgee Local Health District. 2014. Community Health Sustainability Report.
  4. Murrumbidgee Local Health District. 2014. Aged Care Clinical Services Plan.
  5. NSW Ministry of Health. 2014. Acute to Aged Related Care Services Practice Guidelines (GL2014_010).
  6. NSW Ministry of Health. 2014. Aged Care Services in Emergency Teams Practice Guidelines (GL2014_011).
  7. NSW Family and Community Services. 2014. Strengthening supports for children and families 0 to 8 years: Building a platform for the future. (Trim Reference AH14/36944).


Catherine Maloney
Director Allied Health
Murrumbidgee Local Health District
Phone: 02 6382 8776 / 0477 334 428

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