This chapter describes the contemporary roles of health professionals in caring for individuals with a chronic illness and/or disability. Every health professional plays an important role in the interdisciplinary/multidisciplinary team. The chapter also discusses the scope of practice implemented by other health professionals through a team approach to support a person with a chronic illness and/or disability. The very nature of chronic illness and/or disability demands that many health disciplines work collaboratively to manage the complexity and variety of health issues that arise.

The terms ‘interdisciplinary’ and ‘multidisciplinary’ are often used interchangeably in the literature to denote the group of health professionals who comprise ‘the team’ responsible for the provision of care in chronic illness and/or disability. Neal (2004) does, however, distinguish between the two, essentially based on the approach to care employed by the team, which is worth noting. In a multidisciplinary team, it is most likely that the approach to care will be discipline focused (Neal, 2004). Here the health professionals largely work within their discipline base, independently of other health professionals, in determining goals in collaboration with the patient and family. The alternative approach of an interdisciplinary team comprises health professionals from several different disciplines who work collectively to identify and resolve issues through mutually agreed upon goals with the patient and family (Morris & Edwards, 2006). Overall it needs to be recognised that regardless of the label applied to the approach used, team meetings are used to share information and discuss possible solutions to achieving an optimal outcome for patients and their families (Morris & Edwards, 2006).

In this chapter the terms ‘interdisciplinary’ and ‘multidisciplinary’ are used interchangeably by the various authors to enable both approaches to care to be illustrated and contextualised depending upon the needs of the patient/client and their family. The approach in this chapter requires that health professionals and other allied disciplines work collaboratively in determining the priorities and the nature of the interventions to be implemented and in evaluating care provided in a more holistic and cohesive manner. This approach offers the flexibility needed to respond to the changing needs of a person with chronic illness and/or disability and their family. The partnerships created between the person and their family and among various members of the interdisciplinary team intersect with one another and make central the person and their health needs. The interdisciplinary team seeks to resolve issues for the person and their family by determining a shared goal of care, involving a number of strategies that are not discipline-specific but rather conceptualised from knowledge and experience to best suit the needs of the individual.

Effective communication is the key to achieving the goals determined by the team in collaboration with the person. The nurse is equal to all other members of the interdisciplinary team and is most likely to be the primary carer in a range of healthcare settings. As a result the nurse will often assume a coordination role within the health professional team. Having the primary carer assume the coordination role within the team directly benefits the person and their family by bringing together the wealth of knowledge, experience and skills in the planning of a range of interventions to manage the issues arising for people with chronic illness and/or disability. This role is also pivotal in ensuring that the interventions and solutions implemented are evaluated on an ongoing basis and to recognise that as patient/client’s needs change so to does the plan of care.

This chapter describes the roles of the dietitian, general practitioner, occupational therapist, physiotherapist, speech pathologist and social worker in an interdisciplinary team.

In the hospital and the community the dietitian is part of a professional interdisciplinary/multidisciplinary team that aims to prevent, treat, manage and improve individual and community health. Dietitians are specialists in human metabolism and the nutritional value of food and their pathogenic impacts on the health of the human body.

An Accredited Practising Dietitian (APD) is registered with the Dietitians Association of Australia (DAA) after qualifying from an accredited course in nutrition and dietetics. Such a course means at least four years of university training in the science and art of food and nutrition.

A dietitian’s primary aim is to improve individual and community health and wellbeing through food. They assist people to understand the relationship of food to health and how to make healthy food choices. Nutritional advice is in strong demand, given the increase in the incidence of diet-related diseases, which often lead to chronic disease and disability (Wahlqvist, 2002). A dietitian uses a range of techniques to assess nutritional status, identify specific problems, counsel for better health outcomes and plan and evaluate for patient care.

Dietitians work in a range of public and private settings and with people of all ages. They may work as clinical dietitians, as public health nutritionists, as nutrition service managers or private practitioners. Figure 2.1 shows where APDs are employed in Australia.

FIGURE 2.1 Employment of Accredited Practising Dietitians in Australia

Source: DAA, 2007b

The scope of dietetic practice varies with each setting and includes individual patient care, assessment, education and prevention. With the rise in diet-related diseases dietitians are often engaged as public health nutritionists, working at the local community level or at a national level, to design and implement health improvement programs aimed at decreasing the risk factors associated with chronic and preventable diseases.

A clinical dietitian works with people with particular medical conditions and is responsible for all aspects of nutritional care and nutritional intervention. This may include assessing needs for therapeutic or special diets. It may also include making recommendations to medical staff for biochemical tests, nutrition supplements and modes of feeding such as tube feeding and total parenteral nutrition. Nutrition education for patients and their families is an important aspect of a dietitian’s role in any setting.

Dietitians have to deal with a range of scenarios from developmental anomalies to acute care and the ongoing management of chronic and debilitating conditions. Dietetic practice follows the DAA’s best practice guidelines, which support specialised fields of treatment and management, such as paediatrics, cystic fibrosis, heart disease, hyperlipidaemia, diabetes, cancer, pregnancy, renal disease, anorexia nervosa, coeliac disease, malnutrition, weight management, undesirable weight loss, disability services, food allergy or intolerance, sports nutrition and so on. Dietitians are great resources for other disciplines, patients and caregivers. They provide appropriate advice on nutrition for the patient and their family. This may include enteral and parenteral as well as oral nutrition.

The medical practitioner, with the other health professionals, assists the patient to achieve their goals in self-care. Clearly, the role of medical practitioners is to identify medical and other problems and, in concert with the patient, devise strategies to manage them. Problems identified may require a medical intervention such as a drug or an operation. However, many of the problems will require other assistance to manage the problem. This may involve health education, ventilation of anxieties, allied health support, the arrangement of aids of daily living or attendance to psychological or spiritual issues. This is a very complex role (Stewart et al, 2003). Full implementation of the development of a care plan requires coordination of care. In Australia, this role is evolving from a doctor-focused approach to a multi-disciplinary one.

Community-based medical services are organised in different ways in different countries. The position of primary care in the health system varies. In the UK, Canada, Australia, the Netherlands and most Scandinavian countries, for example, the primary care practitioners are the patient’s point of entry to the health system: referrals to specialist care take place via them. In other places, primary care doctors are but one of many medical specialties to whom a patient can present directly. Starfield has shown conclusively that the health of a nation’s population is directly proportional to the degree to which the primary care sector is valued and resourced (1991, 1994).

Primary care medicine is also funded in different ways. In Australia until 1999, the general practitioner (GP) was funded on a fee-for-service basis only, and no substitution of services by other health professionals on behalf of the GP was permitted. (These rules are identical to those related to consultation reimbursement currently in force (Medicare Australia, 2007).) That is, the GP had to see the patient and deliver the service personally in order to attract government-supported payments. Practice staff could not render the service for them. This is in sharp contrast to the UK model, where the general practice is the unit of care, and the GP heads a team of several health professionals who provide the care. The practice is paid a per capita fee to deliver primary care services to a defined group of patients, with the fee increasing if certain health targets (e.g. a percentage of patients immunised for influenza annually) are met. Teamwork in this setting is clearly encouraged (Weller & Maynard, 2004).

Since 1999, there has been a marked shift towards multidisciplinary care. Health planners have recognised that comprehensive care cannot be delivered by one health practitioner in isolation, and funding models have shifted to accommodate this. Health outcomes are better when patients are cared for in teams, with purposive planning of the care. For example, in the care of chronic obstructive pulmonary disease, patients have improved function, are more independent and have better quality of life when they are treated by multidisciplinary teams (Tieman et al, 2006). Similarly, diabetic patients who have comprehensive care by a general practice-based team have improved outcomes, to the point that their risk of an adverse vascular event such as a heart attack or stroke in the next five years actually falls by 25% over two years (Ackermann & Mitchell, 2006).

From the medical practitioner’s perspective there are several models that can be used. All have the following requirements.

Such a system has evolved in Australia since 1999. This federal government initiative has facilitated multidisciplinary care for the first time, and funded GPs to take part in existing multidisciplinary care teams, such as those that exist in specialist palliative care services. In addition, the funding scheme allows certain patients (older people and intellectually disabled people) to be assessed for potential health problems that may not be readily detectable in a routine medical consultation. This allows appropriate multidisciplinary health interventions to be planned and delivered to prevent more serious and intractable problems from arising at a later date (Medicare Australia, 2007).

Once a multidisciplinary management plan has been devised, the funding mechanism supports limited allied health interventions. Routine follow-up of patients is encouraged by the program. A similar but parallel scheme has been developed for the care of mental health problems in community patients.

Following are two examples of the way such programs can work. In Case Study 2.1 a multidisciplinary care program has been put in place within a rural general practice for diabetic patients. The features of this model are that every diabetic patient is offered the service, and programmed recall is arranged every three months. The nurse works to a plan to review the patient, advising the doctor of findings to be reviewed. The doctor then arranges for individualised, ongoing care (Ackermann & Mitchell, 2006). In Case Study 2.2, case conferences and care planning take place between the team at a specialist inpatient stroke unit and all persons are involved in the early discharge of the patient to home. The participants all contribute to the care planning, the tasks are allocated clearly and there is a definite follow-up plan to ensure all planned treatments are carried out (Fjaertoft et al, 2004; Fjaertoft, Indredavik & Lydersen, 2003; Fjaertoft et al, 2005; Indredavik et al, 2000).

CASE STUDY 2.1

INTRA-PRACTICE MULTIDISCIPLINARY CARE (ACKERMANN AND MITCHELL, 2006)

Setting: Regional Australian town, district population 25,000

Patients: All diabetic patients of the practice n = 700; 404 participated

Multidisciplinary team members: GP, practice nurse, visiting diabetic educator, visiting dietitian

Structure of multidisciplinary care: Patient reviewed by nurse, protocol of review developed by practice based on evidence-based best practice. GP reviews patient, being alerted to features required to manage. GP refers to other team members as required. Patients recalled for review every three months.

Outcomes: Population improvements in abdominal circumference, systolic and diastolic blood pressure, HDL and LDL cholesterol, and five-year risk of cardiovascular events, proportion of patients suffering severe hypoglycaemia in last 12 months, and proportion of foot lesions; proportion of patients at or below recommended blood pressure and cholesterol readings increased (all p<0.05) over two years.

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