Community Multi-Disciplinary Team

The development of a strong multi-disciplinary team (MDT) is an integral component of CBCS’s  community-based high utilization program. Generally, high utilization clients need help from many resources in the community.  By engaging them in a common approach to client care it serves multiple purposes:

  • Clients get the care they need faster as many resources involved in their care work together towards seeking their ideal outcomes
  • Community care becomes more efficient as the multiple resources involved in high utilization cases begin to better understand each other’s capacities and limitations, and more effectively work together towards the most effective approach to care
  • Improved cost of care as resource utilization amongst involved entities is streamlined

When working to develop your MDT with CBCS, we will be typically on-site for 2-3-day periods each month. During the first month our focus will be on:

  • Identifying the community needs and resources most affected by high resource clients, and engaging them in participation in the MDT program
  • Working with the contracting agency to identify the appropriate program patients
  • Working with the contracting agency to identify the assigned program staff member, and begin training them on MDT administration

Once assembled, the MDT group will begin meeting in month two.  Meetings are typically 90 minutes long and involve a review of about 5 patients per meeting; short updates on previously reviewed patients also occur. Typically, by month four assigned staff should be able to run the MDT program by the end of the six-month contract period. In addition to monthly on-site visits, CBCS staff will meet with assigned program staff for weekly teleconference meetings, and via phone and/or additional teleconferencing as needed.

MDT membership varies depending on community needs; core members are typically representatives from local emergency departments, large primary care groups and/or FQHCs, EMS organizations, and behavioral health and substance abuse treatment centers. Ad-hoc (invited as needed for specific cases) members may include representatives from therapeutic court and legal systems, jail/prison programs, housing authority groups, law enforcement agencies, and others. CBCS encourages contacting entities to submit patients for enrollment into the MDT program that they have found to be particularly difficult to engage, and/or have difficult case management histories.

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