China has worked to establish multidisciplinary teams across levels of care as a part of the Joint Management by Three Professionals (JMTP) reform in the city of Xiamen. The JMTP leverages a tiered health service delivery approach to the management of chronic disease with a focus on increasing patients’ use of community resources and strengthening systems for role delineation.1 The JMTP reform tackled this in two ways, strengthening diagnostic and treatment capacities at the PHC level and implementing standardized care pathways across community centers. Multidisciplinary care teams are the vehicle for care management of complex conditions. These teams consist of a specialist, general practitioner, and health manager to provide preventive, promotive, curative, behavioral and rehabilitative services at the community level. Each team member has a defined role that serves to enhance patients’ equitable access to the diagnosis and treatment of complex conditions. In this hierarchical role structure, the specialist determines the diagnosis and treatment plan, the general practitioner implements the plan and conducts daily monitoring, and the health manager handles health education and behavior-related interventions. To promote community-based care, these teams conduct home visits and encourage the use of community health centers as the usual source of care.1 When necessary, the general practitioner provides two-way referrals to secondary and tertiary hospitals in accordance with standardized referral pathways, reinforcing gatekeeping structures that promote primary care as the first point of contact and main coordinator of care.

References:

  1. WHO. China: Multidisciplinary teams and integrated service delivery across levels of care. World Health Organization; 2018.