1. Multi-disciplinary Team Meeting
PPG meeting
19/03/16
Dr Barretto & Partners PPG Meeting 19/03/16

2. those patients that are at
MDTs were started for:
those patients that are at
High risk of admission within the next 12 months
Have complex needs that may benefit from a co-ordinated approach involving Health and/or Social Care.
Patients whose needs are likely to increase in the near future, thus providing the opportunity for Health and Social care partners to agree proactive response and support in advance.
Dr Barretto & Partners PPG Meeting 19/03/16

3. From 2014/15, each Practice has had a monthly MDT meeting involving
A Gp and an Administrator from the Practice
The Network Support Team members, (NST) or the core team who are the community Matron and the Social Worker
The palliative care nurses from St. Christopher’s
Dr Barretto & Partners PPG Meeting 19/03/16

4. Discussions for palliative care patients.
Patients are identified by members of the MDT - added to the list at least a week before meetings.
At the start of the meeting the team discusses and reviews any very high risk/urgent cases from previous meetings. 
Discussions for palliative care patients.
Dr Barretto & Partners PPG Meeting 19/03/16

5. The date for the next meeting is agreed at the end of the meeting.
A Personalised Care Plan (PCP) is developed by the practice (with the patient if appropriate).
At the MDT the PCP can be reviewed by the team and any additional information recorded onto the care plan.
The date for the next meeting is agreed at the end of the meeting.
Minutes are sent round via with the actions to be taken by members clearly identified.
Dr Barretto & Partners PPG Meeting 19/03/16

6. Questions?
Dr Barretto & Partners PPG Meeting 19/03/16