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SP0095 How A Multi-Disciplinary Team Improves Patient Outcomes
  1. T. Vliet Vlieland1,2,3
  1. 1Sophia Rehabilitation, The Hague
  2. 2Rijnlands Rehabilitation Center, Leiden
  3. 3Orthopaedics J11-R, Leiden University Medical Center, Leiden, Netherlands


According to the Chronic Care Model, outcomes of health care for people with chronic musculoskeletal and rheumatic diseases (RMDs) depend, apart from characteristics of the health system and the community, on a productive interaction between the informed, activated patient and a prepared, proactive practice team. A team is defined as a small number of consistent people committed to a relevant shared purpose, with common performance goals, complementary and overlapping skills, and a common approach to their work. A multi-disciplinary team for people with inflammatory RMDs usually comprises the rheumatologist and professionals from other disciplines such as a nurse, physical therapist, occupational therapist, social worker, psychologist or podiatrist or other, some with extended scope of practice. However, dependent on the nature and severity of the RMD and local availability of skilled health care providers, the composition of the multi-disciplinary team may vary.

Overall, evidence from systematic reviews as well as individual clinical trials supports improved functioning following multi-disciplinary team care for a number of RMDs1. However, research also illustrates that multi-disciplinary team care can be effective in several forms, as the multi-disciplinary interventions described in the literature vary largely. This variation does not only include the professionals involved, but also the treatments provided (content, intensity, complexity), the setting (primary care, secondary care and/or community), the method of communication with the patient and among professionals (face-to-face contacts, telephone, videoconferencing or other web-based modes for communication) and many other factors such as funding and the use of process and outcome measures for evaluation.

As currently the right care is not consistently delivered to the right person, at the right time, in the right place or by the right team2, challenges for the future are to further identify the key components of effective multi-disciplinary team care interventions and how their implementation can be supported across health care services in different health care systems. For that purpose, the consideration of alternative, network-based models of engagement and collaboration for clinicians, consumers and other stakeholders and the optimization of the use of digital technologies, as well as formal evaluations of effectiveness and costs are indispensable2,3.


  1. Momsen A-M et al. Multidisciplinary team care in rehabilitation: an overview of reviews. J Rehabil Med 2012;44:901-912.

  2. Speerin R et al. Moving from evidence to practice: Models of care for the prevention and management of musculoskeletal conditions. Best Practice & Research Clinical Rheumatology 2014;28:479-515.

  3. Brand CA et al. Chronic disease management: improving care for people with osteoarthritis. Best Practice & Research Clinical Rheumatology 2014;28:119-142.

Disclosure of Interest None declared

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