Principle 7: Multidisciplinary services

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Multi-purpose services use a multidisciplinary team to provide person-centred care based on each resident's needs, choices and availability.

The care aims to maximise functional ability and quality of life of people with:

  • chronic conditions
  • disability
  • pain
  • increased risk of falls
  • increased risk of depression
  • other health conditions.

Established care pathways are negotiated with local service providers to ensure timely access. Efforts focus on preventing falls and promoting health through therapeutic interventions and activities. Virtual care services can be used to ensure residents get the support they need.

Collaboration leads to better outcomes

An MPS resident visits the Junee Men's Shed.

Nurses, doctors, Aboriginal health workers and allied health professionals work together to provide multidisciplinary care that addresses the diverse and complex needs of older people.

This collaboration allows for comprehensive assessments, specialised expertise and personalised care plans tailored to each resident's unique needs and preferences. Effective communication and coordination among team members improves care and promotes better health outcomes.

Allied health professionals have a crucial role in preventing falls and reducing fall-related injuries. The Australian Commission on Safety and Quality in Health Care has produced national guidelines to inform clinical practice and support residential aged care facilities to implement routine multidisciplinary falls prevention interventions.1

Explore different healthcare options

Establish referral and service delivery pathways

  • Identify and negotiate referral pathways within the local health district to share staffing and resources.
  • Collaborate with public, private and non-government providers to share resources.
  • Include outreach services from larger regional centres.
  • Use virtual care to increase access to multidisciplinary services for residents.

Support resident choice

  • Enable access to private healthcare providers.
  • Promote the use of available Medicare and private health insurance options.
  • Offer services that are culturally and personally appropriate.

Incorporate health promotion

  • Promote physical activity and offer exercise interventions.
  • Reduce risks related to polypharmacy and under-treated conditions with regular medication reviews.
  • Explore options for workforce remodelling to improve access to lifestyle activities.

Strategies for small-scale change

Enable access to funded care options

  • Use Chronic Disease Management items for up to 5 Medicare-funded allied health visits per year. Additional visits are available for Aboriginal and Torres Strait Islander residents.
  • Use the Medicare-funded Residential Medication Management Review to ensure appropriate medication, with one review payable per resident annually.
  • Allow residents to choose private services, e.g. dental, physiotherapy, podiatry, using private health insurance when available.

Set up or strengthen referral pathways

  • Develop service level agreements with non-government providers, Aboriginal Medical Services, and regional referral centres.
  • Trial hub-and-spoke models for visiting services like oral health, wound care or social work for end-of-life support.

Support virtual care

  • Promote virtual care for specialist consultations and regular reviews, e.g. dietetic, medication, speech and swallowing assessments.
  • Establish mentor or virtual care support through larger regional centres.
  • Train staff in virtual care.

Provide exercise interventions

  • Build physical activity into the daily routine.
  • Introduce basic strength or balance programs led by trained staff or external providers.
  • Use assistants in nursing, allied health assistants, activity officers, diversional therapists and Aboriginal health workers to support an increased uptake of physical activity. While these disciplines cannot prescribe exercise, they may be able to support a program under the supervision of an allied health professional.

Explore options for workforce remodelling

  • Use local allied health assistants, activities officers and Aboriginal health workers as a part of the multi-disciplinary team.
  • Use this workforce to support exercise groups, falls prevention, recreational activities and mealtime support.
  • Consider including the role of dining ambassadors.

    In practice: Innovative dental care improves health

    The ResiDENTAL program is an initiative of Hunter New England LHD Oral Health. The Resi Van travels to each MPS and provides dental treatment to the residents using portable dental equipment.

    Before a ResiDENTAL Clinic, MPS staff collect dental consent forms and update Hunter New England Oral Health with each resident’s medical history. Between scheduled visits, Oral Health provides real-time dental reviews via virtual care.

    MPS nursing staff are trained to operate intraoral cameras, providing the hands-on support for the virtual consultation. The virtual consultation with dental professionals empowers nursing staff to proactively address oral health concerns and improve care for residents.

    References

    1. Australian Commission on Safety and Quality in Health Care. Falls. Sydney, NSW: ACSQHC; 2026 [cited 20 Mar 2026].
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