Patient-centred care and multidisciplinary issues - role of multidisciplinary team members in diagnosis and management

Overview

Management of older patients, particularly those with complex/multimorbid presentations, relies on a multidisciplinary team - no single discipline has the full skill set to address the medical, functional, cognitive, and social dimensions of geriatric care alone
Multidisciplinary team models (geriatrician, nursing, physiotherapy, occupational therapy, social work, pharmacy, dietetics, speech pathology) are standard in acute geriatric and rehabilitation units, reflecting the evidence that this model improves functional outcomes compared with single-discipline care

Each discipline contributes a distinct, complementary assessment: physiotherapy (mobility/strength), occupational therapy (ADL function, home safety, cognition-function interaction), social work (psychosocial, discharge/placement, carer support), pharmacy (medication review/reconciliation), dietetics (nutrition), speech pathology (swallowing, communication) - together producing a more complete picture than any single medical review

Effective multidisciplinary team function requires structured communication (regular team meetings, shared documentation) so that each discipline's findings inform the overall plan, rather than each operating in isolation with the medical team as the only integration point

The team should set and revise goals collaboratively (see collaborative goal setting) with the patient at the centre, not simply report findings upward to a single decision-maker
Role clarity (who leads which aspect of the plan) prevents both duplication and gaps in care

Comprehensive geriatric assessment, rehabilitation goal-setting, discharge planning, orthogeriatric co-management

The evidence base for comprehensive geriatric assessment and multidisciplinary team management (improved function, reduced institutionalisation, reduced mortality in some settings) is one of the strongest in geriatric medicine, distinguishing it from single-discipline usual care

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