Change 3: Practise effective multi-disciplinary working

Foster trusted and joint assessments, shared decision-making and positive risk-taking to deliver pro-active person-centred care. Working together with individuals, and their family and/or carers can build confidence and facilitate a holistic approach to meeting needs.

This change supports Goal 1: prevent crisis and Goal 2: stop crisis becoming an admission.

Making it Real statements

I have care and support that is coordinated, and everyone works well together and with me."

We work with people as equal partners and combine our respective knowledge and experience to support joint decision-making."

Tips for success

  • Work out who needs to be involved in delivering holistic, person-centred and coordinated care and support in each locality. Working with independent, voluntary, community and social enterprise organisations is important, including for people who are funding their own care.
  • Adapt the membership of your multi-disciplinary team (MDT) according to the care and support needs of your local population and individuals with whom you work. Consider collaborating with professionals from non-social care services and care givers such as mental health practitioners, pharmacists, carers, dietitians, housing representatives (such as housing or homelessness officers or home improvement agency staff), and any other specialists who may bring expertise and coordination.
  • Successful joint assessments and care planning can prevent admissions when people and their family and/or carers are involved in, and share, the decision-making. This can be underpinned by shared care records and standardised documentation practices across the MDT and care providers.
  • Using trusted assessment principles to carry out a holistic assessment of need avoids duplication and can reduce the time someone waits to be assessed. This can be undertaken by the best-placed person who is involved in the person’s care, for example social worker, community physiotherapist or crisis response team.
  • Train team members to identify how health and wider inequalities impact on population groups, individuals and their carers to find solutions that help to mitigate their risk of admission.
  • Train members of MDTs in shared decision-making, strengths-based approaches and positive risk-taking so they are confident in having honest conversations with individuals, and their carers, about their options. Frontline staff should feel comfortable discussing options, risks and benefits with individuals to weigh up their preferences and capabilities for self-management.
  • Meeting regularly in a ‘huddle’ can help multi-disciplinary colleagues to plan proactively the care of people with more complex needs to reduce the risk of admissions.
  • Provide training, forums or peer-learning meetings that support dialogue and reflections among different roles involved in admission avoidance to foster trust and an open culture within MDTs.
  • Develop and maintain close joint working with local welfare and benefits advice, housing information and advice services so that staff can help people find and use up-to-date sources, including local directories.
  • Link services’ regular monitoring of individuals who are at risk of an emergency admission including those who have intensive or complex care packages, frequent health crises and GP call outs, multiple outpatient appointments or are near the end of their life.
  • Regularly review how effectively people are handed between services and work collaboratively to improve processes along the whole admissions avoidance pathway.
  • Focus on using proactive case management approaches and support to provide home-based care rather than secondary care.
  • End of life care, including advance care planning must always be personalised. The individual must be the decision-maker for their care at the end of their life, supported by informed discussions with their MDTs. Hospice at home models and community specialist palliative care teams, some of whom operate through hubs which are set up to respond to crisis situations, can make an important contribution to care at home and reduce preventable admissions.
  • Consider moving towards a transdisciplinary model where one discipline may take on the traditional function of another by agreement. 

Examples of emerging and developing practice

Supporting materials

Making it happen: Multi-disciplinary (MDT) team working, NHS England, January 2015.

Positive risk taking, Joseph Rowntree Foundation, 2014.
Enhanced Health in Care Homes, NHS England and Improvement, March 2020.
End of life care: guide for councils, LGA/ADASS, September 2020.
Ambitions for Palliative and End of Life Care, A national framework for local action 2015-2020.
Making decisions on the duty to carry out safeguarding enquiries, Making Safeguarding Personal, ADASS and LGA, August 2019.

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