An interdisciplinary team (IDT) brings together knowledge from different health care disciplines to help people receive the care they need. For example, in the disability-competent care (DCC) model, the core members of the IDT include a primary care provider (PCP), a care coordinator, a nurse, a social worker, and a behavioral health specialist. Other health care providers, such as rehabilitation specialists, durable medical equipment (DME) specialists, and hospitalists, may also be included as needed.1 Through interdependent collaboration, open communication, and shared decision making, IDTs generate improved outcomes. Successful IDTs use a person-centered approach that prioritizes the individual’s needs.2
Using an IDT can be a helpful tactic to deliver quality health care and outcomes for the dually eligible population. Individuals who are dually eligible for Medicare and Medicaid experience high rates of chronic illness, with many having long-term care needs and social risk factors. Forty-one percent of dually eligible individuals have at least one mental health diagnosis, 49% receive long-term care services and supports (LTSS), and 60% have multiple chronic conditions.3,4 To fully address their needs and risk factors, members of this population often require multiple medical specialists, a range of health and social services, and immediate responsiveness to prevent the development or escalation of acute conditions—IDTs can provide the needed coordination of care. Resources for Integrated Care has developed resources to help providers and plans serving dually eligible beneficiaries using, or considering using, IDTs in their organizations.
1 Resources for Integrated Care. (2019). Topic Summary: Interdisciplinary Team Building, Management and Communication. Retrieved from https://www.resourcesforintegratedcare.com/DCC_Topic_Summary_Interdisciplinary_Team_Building_Management_and_Communication.
2 Resources for Integrated Care. (2017). Interdisciplinary Care Teams for Older Adults. Retrieved from https://www.resourcesforintegratedcare.com/GeriatricCompetentCare/2017_GCC_Webinar_Series/ICT.
3 Physical and Mental Health Condition Prevalence and Comorbidity among Fee-For-Service Medicare-Medicaid Enrollees. Centers for Medicare & Medicaid Services, September 2014. Available at: https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/Downloads/Dual_Condition_Prevalence_Comorbidity_2014.pdf.
4 Medicare-Medicaid Enrollee Information, National 2012. Available at: https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/Downloads/NationalProfile_2012.pdf.
