What are multidisciplinary, person-centred care pathways?
Person-centred care (PCC) prioritises the needs and preferences of the older person in the planning and delivery of their care, described as holistic, individualised, empowering care. [1] It can provide guidance for how to centre the older person in their care.
Multidisciplinary care (MDC) includes practitioners from different disciplines working together as a team to provide care to an older person. There are many ways for teams to collaborate.
Both of these models of care are required by the Aged Care Act to shift from task-based care to a holistic, rights-based approach. [2]
Why do PCC and MDC matter for rights-based care?
PCC and MDC are core obligations for providers under the Aged Care Act. Standard 1 requires providers to tailor care to the individual’s needs, goals, and preferences. Standard 5 requires care to be delivered by a skilled multidisciplinary workforce. Providers must ensure effective communication between the care team, the older person, and their families. [2]
Person-centred care
PCC is central to rights protection. [3] It is linked to RBC principles, including dignity, autonomy, responsiveness, accountability, choice, control, self-determination and consent. [4-6]
In one study, PCC was described as a component of an overall model of aged care focused on dignity, rights, and social inclusion. [7] In a study of PCC for LGBTQ+ older people, PCC was integrated across activities such as education, inclusion, visibility, and unity. [8]
PCC can include specific interventions that can be delivered to an older person, such as person-centred care planning, [9, 10] and shared decision-making. [3] While individual staff actions are important, they must be supported by organisational policies and practices. One study described PCC as an intervention umbrella that included individualised activities, staff training, and behavioural and culture change approaches. [11] Another included staff training, organisational policy, and scenario-based response strategies. [12]
There is limited evidence about the effectiveness of PCC, but studies showed some positive effects. PCC was linked to improved wellbeing when supported by leadership. [11] It was also shown to reduce embarrassment and loss of self-worth. [13]
Good implementation strategies can lead to more effective PCC. Organisational culture, leadership, and training are necessary to support it. [8, 11, 14] PCC may be embraced in principle, but implementation in practice can be inconsistent. [3, 15]
Multidisciplinary care
MDC is essential to respecting autonomy, dignity, choice, and control. [4, 16] It has been described as an enabler of care quality and a safety mechanism. [1, 17]
MDC can also be formal or informal. It may include organisational teamwork or a collaborative culture; specific activities that require multiple perspectives; or formal roles, structures, and procedures that make MDC systematic and embedded. [17-19]
One example of formal MDC is an interdisciplinary care team that includes clinicians, case managers, social workers, and nurses in end-of-life decision-making. These teams assess, plan, and deliver care jointly rather than each working on their own with separate care plans and treatment activities. [16]
Another study suggested MDC teams comprised of nursing, allied health, and specialist practitioners. They identified specific activities where MDC can be useful for reducing physical restraint: in clinical handover, and in care planning. [17]
MDC was also identified as a helpful way to enhance assessment of decision-making capacity. Combining insights from different disciplines in a purposeful way could strengthen these assessments. [19]
While MDC usually refers to teams within the same organisation, there is a need for multidisciplinary coordination across different parts of a health or aged care system. Transitions from hospital to residential settings, for example, could be improved if MDC was more coordinated between the two settings. MDC across different providers is necessary to ensure that older people have meaningful choice and control. [4]
Both person-centred and multidisciplinary approaches can help providers deliver rights-based care, and MDC can be an enabler to person-centredness. Like PCC, MDC faces implementation challenges. Teamwork is critical to quality care, but it can be difficult to prioritise when there are workload and other organisational pressures. [1]
Want to learn more?
The Comprehensive Care Standard aims to ensure that patients receive comprehensive health care that meets their individual needs.
This training module from Ausmed explores how to align with the Statement of Rights in the Aged Care Act by providing person-centred, rights-based care.
This report by the Consumer Health Forum Australia and the George Institute for Global Health puts consumers at the heart of care and decision-making.
Read more about the Multidisciplinary approach theme in the Rehabilitation, Reablement, and Restorative Care priority topic.
What can be done?
Support teamwork as an enabler of PCC in daily practice
Aged care workers:
- Actively support teamwork through information sharing, joint problem-solving, and peer support.
Providers:
- Ensure PCC is reflected in policies and procedures, governance structures, and quality systems.
The evidence:
- Teamwork is a key enabler of translating PCC principles into daily practice. [1]
- Whole of organisation collaboration is essential to create inclusive, person centred environments. [18]
- PCC requires organisational and governance support. [6]
Provide training that supports teams to deliver PCC
Aged care leaders:
- Provide training in PCC to support workers to centre the needs and preferences older people in their care.
- Use team discussions and supervision to work through tensions related to PCC and time pressure, staffing, and organisational demands.
The evidence:
- PCC principles are widely endorsed but inconsistently enacted in everyday care. [3]
- Training in human rights-based approaches helps operationalise PCC in everyday practice, particularly where staff must balance autonomy and duty of care. [14]
- Lack of standardised training can be a barrier to implementing person centred planning and practices across services. [9]
Enable multidisciplinary decision‑making for complex or high‑risk care decisions
Aged care leaders:
- Establish routine processes for interdisciplinary or multidisciplinary decision-making, particularly for end-of-life care, restrictive practices, or high-risk autonomy and safety decisions.
- Use multidisciplinary reviews and care planning to identify alternatives to restrictive practices.
The evidence:
- Interdisciplinary team based approaches are essential for ethical end of life decision making and respecting autonomy and dignity. [16]
- Multidisciplinary collaboration can help prevent physical restraint use, improving care quality and safety. [17]