Background

Recent literature calls for a reorganization of the care system to better meet the growing needs of people with complex chronic diseases. The use of multidisciplinary teams (MDT) in community-based primary care offices has been shown to improve patient outcomes. Complex Care Plans (CCPs) are a unique and comprehensive annual plan for a patient with complex chronic care needs. Eligible patients must be diagnosed with at least two of a specific list of chronic medical conditions or one chronic medical condition and a mental health issue, obesity, or an addiction.

Objectives

(1) Describe the processes of execution of Complex Care Plans (CCPs) in primary care physicians' offices. (2) Determine the impact of the involvement of multidisciplinary teams in the execution of CCPs in terms of patient outcomes. (3) Investigate the impact of CCPs on patient outcomes.

Method

(1) Mail survey querying physicians as to the use of the CCP in their office. (2) Patient surveys and a chart audit to evaluate outcomes associated with the presence or absence of a multidisciplinary team. (3) Charts evaluated 6 months after the implementation of a CCP to assess the impact on outcomes.