Multidisciplinary Team Summary

A multidisciplinary team is led by a primary care provider with support from a case manager and consultation from a psychiatrist who providers treatment recommendations for patients who are not achieve clinical goals. The team is population focused and utilizes tools such a disease registry to assist them in monitoring treatment engagement and response to care. Together, this team uses measurement-guided patient-centered outcomes to guide the delivery of evidence-based care in order to achieve “treat-to-target” clinical goals for each patient. These core processes, in aggregate, allow each team to be held accountable to the care they provide and improve upon their processes of care to achieve better outcomes in cost savings, satisfaction, access