Sharing the care - Multidisciplinary team-based models

By Nick Buchan, Primary Times chief writer and Melanie Irwin, Primary Times chief writer  

Source: APNA Primary Times Winter 2023 (Volume 23 Issue 1)

Last edition we looked at the role of new digital technologies in health care and their impacts on nurses’ day-to-day work. In part two of our series that looks to the future of primary health care (PHC) nursing, we consider the nurse’s evolving role as part of a multidisciplinary team. The Albanese Government is funding increased access to multidisciplinary care (amongst other new measures) and the scope of PHC nursing is set to expand. Here’s what you need to know. 

The aged care crisis. Health-care staff shortages. Bulk billing in freefall. The ever-rising demand for health-care services. When the Albanese Government was elected in May 2022, it faced an immediate PHC sector crisis on several fronts.  

And when it came to PHC nurses, the issues were even more acute. Nurse burnout, restricted scope of practice, staff retention problems, and GP-focused funding structures were just some of the problems needing urgent attention. 

With the suitability of Medicare being called into question, the government committed to taking action quickly. And it did, forming the Strengthening Medicare Taskforce (SMT) in July 2022 based largely on a similar group that had informed the 10 Year Primary Health Care Strategy for the previous Coalition government. This group was focused on what could be done in the near term to strengthen Medicare, backed by billions of dollars in additional Commonwealth Government funding. It also aimed to lay the foundations for longer-term reform and investment in the PHC system.

APNA President Karen Booth was an SMT member and worked hard to ensure that the needs of PHC nurses were heard clearly by decision-makers. As a result, one of the main recommendations of the final report to government was a focus on multidisciplinary teams working to their full scopes of practice to provide person-centred comprehensive care. In addition to this, the other SMT recommendations were to modernise and increase access to primary care, and to support change management and cultural change.

It’s promising to see now that the government has responded proactively to the SMT’s recommendations. As part of the government’s May 2023 budget, an ambitious package of measures will be implemented to strengthen access to PHC, including funding for multidisciplinary team-based models.2,3,4 

‘We can expect to see a broadening of the understanding of PHC. All team members, including PHC nurses and allied health practitioners, will work to their full scopes of practice to improve the health of Australia.’ 

While this increased funding for multidisciplinary teams is a good start on a long path to health system reform, there are several welcome policy advances for PHC nurses, including a scope of practice review (more on this later). Over the coming months and years, we can expect to see a broadening of the understanding of PHC as well as steps to enable team-based care, where all team members, including PHC nurses and allied health practitioners, will work to their full scopes of practice to improve the health of Australia. 

But how do these multidisciplinary models work in practice? How long will they take to implement? And what will a team-based model of care mean for the health system over the long term? Here, we take a look at the government’s planned reforms and ask some experts about what’s to come. 



MyMedicare is a new voluntary patient registration (VPR) model that the Commonwealth will introduce before the end of 2023. Designed to improve continuity of care for Australians,3 the model will encourage patients to register (or enrol) with a PHC practice for long-term care.  

VPR has been shown to improve the efficiency and effectiveness of health-care systems5 and it helps general practices to run more smoothly. ‘Practices will be able to plan ahead,’ Karen Booth says. ‘They can look at what their patients’ care needs will be over the long term. It will be much more predictable for practices and patients.’  

Under the current Medicare billing system, the doctor must see the patient every visit. ‘Hopefully, MyMedicare will encourage practices to use their other team members, including nurses, in a more flexible way,’ Karen says. ‘For patients with chronic disease, nurses will be able to take a caseload and do most of that management. Instead of having to see the doctor every visit, the patient might just come in for a dressing with the nurse and see the GP only when needed. We hope to see a shift in the funding model where payment is attached to the patient’s care episode and not to the doctor’s MBS activity.’ 

Tracey Johnson is the CEO of Inala Primary Care, an innovative multidisciplinary general practice in Brisbane. Her team includes GPs, a large team of nurses, non-dispensing pharmacists and allied health practitioners. Tracey agrees that VPR will enable general practices to plan the care they provide more effectively: ‘We’ve got to enrol people to know who our population is,’ she says. ‘At Inala Primary Care, we believe in continuous comprehensive health care, and that’s what VPR does. When a patient commits to a practice, they benefit from that continuity with a care team who knows them and knows what’s important to them. As care providers, we also benefit from VPR, because we know what to expect on a day-to-day basis, which allows us to provide better care and to avoid burnout. It’s a win–win situation.’  


Wraparound primary care 

Another government initiative that responds to the SMT’s recommendations is a wraparound care model that will be linked to MyMedicare. This new blended funding model will support general practices to provide comprehensive clinical care for patients who are frequent hospital users, residents of residential aged-care facilities and those who have complex chronic conditions.3 

‘Nurses will be doing more. Instead of having to see the doctor every visit, a chronic disease patient might just come in for a dressing with the nurse and see the GP only when needed.’ — Karen Booth 

According to Tracey, flexible funding for team-based chronic disease care will improve access to health care for everyone. ‘Doctors’ schedules are currently being filled with appointments for elderly patients and those with chronic disease, which means they can’t take new patients,’ she says. ‘This is a problem that’s happening around the country. If some of these regular health check-ups could be done by other team members, such as nurses, that would free up the doctors to take on new patients. It would also give them more time to attend to acute patients, to do diagnosis, complex therapy management, and certain types of therapeutics. This is the higher-value care that doctors should be doing, while other team members share more of the load.’ 

This new wraparound chronic disease model will be designed and implemented in 2023–2024. 


People-centred care 

A team-based multidisciplinary model of care will be a significant move away from the traditional Medicare model. However, John Bruning, CEO of the Australasian College of Paramedicine, believes that the potential benefits of team-based care align with the SMT’s aim of putting people at the centre of health care. 

‘Currently, our system is designed around the GP or the health practitioner,’ John says. ‘You can go and sit in a GP’s waiting room for an hour, and that's not care based around the individual. That's care based around the GP as the centre of the model. Multidisciplinary team care must start with the consumer.’ 

Tracey Johnson agrees: ‘In the past, we’ve had a system much too oriented to what’s important to providers. We need to be asking “What’s important to the patient?” so that we can deliver to the patients what they value. If they value it, they’ll advocate for it politically, and they’ll also value it because they’ll get to experience better care.’ 

Both John and Tracey warn that change is difficult and that there’s bound to be resistance. 

‘There are players in the health system saying, “Hang on, a nurse can't do that, a paramedic can't do that.” Now actually, they can, and they should,’ says John. ‘I think that the challenge for some in the medical profession is relinquishing some control. But the absolute upside for these players is that they will get to use their capabilities and skill set for higher-value care.’ 

Tracey agrees: ‘Some people are so familiar with what they do, they find it hard to imagine a world that’s different,’ she says. ‘The reality is, we’ve got to make the health care budget stretch further. We must embrace more cost-effective ways of delivering care, and multidisciplinary teams provide comprehensiveness, which adds to cost-effectiveness.’ 

John says that while paramedics and PHC nurses may not have worked together much in the past, their skill sets make them natural team members. However, he suggests that the transition to multidisciplinary models won’t happen overnight. 

‘Some people might be worried that health care centres will employ a paramedic instead of a nurse, or a nurse instead of a paramedic, and I don't see that,’ he says. ‘These disciplines will work well together in a team. There will be some overlap in the middle, but I think that the paramedics will work from the acute end and the nurses from the primary care end.’  


Improving access to multidisciplinary care 

Beginning in 2023–2024, the government will increase payments under the Workforce Incentive Program – Practice Stream to provide flexible funding for multidisciplinary team-based models. In addition to this, Primary Health Networks (PHNs) will have a stronger role in commissioning allied health, nursing and midwifery services in their communities. These measures aim to support treatment of chronic and complex conditions, to improve access to affordable multidisciplinary care and to reduce avoidable hospitalisations, especially in underserved communities.

Dr Dan Halliday is president of the Australasian College of Rural and Regional Medicine and he agrees that the current PHC model needs more flexibility. Dan suggests that general practitioners will retain pivotal roles as leaders and coordinators of primary care teams and as gatekeepers to other medical specialties, but that some communities will rely on care from other health care workers when GPs are not available. 

‘We recognise that in rural and especially remote communities, GPs and rural generalists may not be the regular, on-the-ground team member, and that we need to allow flexibility in the system to ensure viability of services,’ Dan says. ‘People living in rural and remote locations should never have to accept a lesser standard than their urban counterparts. To achieve this, rural and remote communities, starting with the most vulnerable, should be consulted on the specific solutions they require to maintain service viability.’ 

‘In future, nurses in general practice will have a more varied career path. They’ll be respected as professionals in their own right and won’t just be seen as the doctors’ handmaidens.’ — Tracey Johnson 

Bronwyn Morris-Donovan, CEO of Allied Health Professions Australia, agrees that each community should be consulted about its unique health needs. She says she is pleased that PHNs will have a stronger role in commissioning multidisciplinary care, and believes the initiative could lead to more sustainable regional models. However, she cautions that PHNs should avoid a ‘one-size-fits-all’ model for providing team-based care. ‘We are looking forward to working closely with the PHNs to improve access to multidisciplinary allied health services,’ she says.  

Bronwyn is also pleased with the increased funding for the Workforce Incentive Program, but notes that in the past, this program has been counterproductive in that it inadvertently reduced some health care providers’ scopes of practice. ‘There must be accountability for how this funding is used, combined with a robust evaluation,’ she says. ‘Without accountability measures, we run the risk of more of the same, which goes no way toward improving access to multidisciplinary care for consumers.’ 


Expanding scopes of practice 

Commencing in late 2023, a National Scope of Practice Review will consider the barriers and incentives for all health professionals to work to their full scope of practice. This measure aims to optimise the use of the workforce across the stretched PHC sector.3 

‘This could be a real game changer for health care,’ says Karen Booth. ‘PHC nurses account for around one in 7 of the 640,000 registered health professionals in Australia. Increasing their scope of practice and embracing a multidisciplinary model of care will unleash the potential of PHC nurses to create a healthier Australia.’ 

This review will be carried out over 18 months and Karen says that the consequent changes will likely take a few years to roll out. ‘In the hospital system, it is accepted and expected that nurses coordinate all the care for patients, and we’ll see more of this in PHC. Prevention, immunisation, and chronic disease management for me are the biggest areas where things will change in the future and nurses will achieve greater autonomy. More nurses will run specific clinics. The patients will still be members of a practice, with strong connections to their care team, but each team member will be enabled to contribute more effectively.’ 

‘It would be wonderful to see more practices where nurses have direct access to a community pharmacist, and can refer patients to have medications reviewed,’ Karen says. ‘Around a quarter of a million hospitalisations each year are due to medication error, so we need to look at how we reduce untoward impacts on patients and unnecessary hospital admissions.’ 

‘In rural areas where there are fewer doctors, nurses will have a bigger role in care coordination and following up referrals and making sure that patients have access to care, whether it's via telehealth or some other connection to get those other support services they need. According to APNA's Workforce Survey, year after year, one-third of nurses say that they're not utilised to their full skills, so these changes are really overdue.’ 

Tracey Johnson is proud of the multidisciplinary model at Inala Primary Care, which enables nurses to work towards their full scope. ‘We have an amazing group of nurses,’ she says, ‘and they’ve stayed with us for many years. They love the work that we do because we allow them to do as much as possible, under the current funding environment, to work to their top of scope of practice.’ 

Tracey envisions a future in which nurses will be doing much more: ‘I want to see a world where nurses are running hot clinics, with patients who’ve got acute illness on the day. Doctors – through standing orders – could delegate roles to nurses, such as health coach or care coordinator. These roles would include following up with patients who are on a particular care pathway, perhaps they’re taking a new medication, and the nurse’s role would involve monitoring that pathway and supporting their compliance.’  

‘I certainly see nurses playing a much greater role around prevention, social prescribing and care navigation,’ Tracey says. ‘And I certainly see a bigger role for nurses running special interest areas (e.g., well women’s checks, or clinics around aging and certain chronic diseases). I absolutely see nurses leading responses to certain cohorts of patients, under standing orders from doctors.’ 

‘In future, nurses in general practice will have a more varied career path,’ Tracey says. ‘They’ll have new areas of work and different accountabilities. They’ll be respected as professionals in their own right and won’t just be seen as the doctors’ handmaidens. It’s already happening at Inala Primary Care.’ (See below for a description of the multidisciplinary model at Inala Primary Care.) 


Beyond general practice 

Team-based multidisciplinary models of care are also set to extend beyond general practice to all areas of PHC. Nurses working in other sectors will enjoy similar benefits in terms of better recognition of skill set and areas of responsibility. 

Family Planning Australia’s Director of Nursing Antoinette Walsh says PHC nurses are already working within a team-based model in her organisation and that this results in better access to high-quality health care for patients. 

‘At Family Planning, nurses work within their scope of practice by assisting with the insertion or removal of long-acting reversible contraception devices,’ Antoinette says. ‘If nurses could access a Medicare rebate it would be a great cost-effective way to increase access to long-acting contraceptives across the whole PHC setting. I really think that this is a missed opportunity for a highly trained, educated workforce working well within their scope. There just needs to be more flexibility for nurses working around us.’ 

‘We train nurses and doctors in these procedures, and what we see is that with nurses and doctors being trained in the same way, we get the same patient safety outcomes. It is just as safe.’ 


Managing change 

Moving to a team-based model of care is not something that can be driven from the top down – it will require the many parts of the system working together to achieve the best outcome for patients. Kylie Woolcock from the Australian Hospitals and Healthcare Association says that reform will be a big job that will take time and the input of a broad range of stakeholders, including those from outside the health care sector. 

‘We have to recognise that the reform needed for the health system will require a shared vision and collaboration between federal and state governments,’ Kylie says. ‘Not just health but across other sectors too – education, employment, immigration, housing, aged and disability care and more. And while it will take time for that vision to be fully realised, the whole system needs to be clear that it is moving towards that shared vision.’ 

‘A strong and sustainable health workforce requires both an intergovernmental and an intersectoral approach,’ Kylie says. ‘The challenges we are facing with workforce shortages and distribution are global issues, and the evidence is strong that we need political leadership and commitment, with sustained and coordinated investment from governments.’  

‘There is significant evidence for the outcomes that can be achieved with skill-mix innovations, but the evidence for how best to implement and scale these new models of care is comparatively less. At the recent WHO Global Forum on Human Resources for Health, countries discussed how important context was in applying these skills-mix innovations. And that is not only important between countries, but in how we implement new models of care across our regions, allowing flexibility to respond to local needs.’  

Tracey Johnson believes that everyone can participate in the transition to more cost-effective and sustainable models. ‘We need a re-energised, re-engaged health care community that will take responsibility for making the health care system of the future,’ she says. ‘And that means taking risks! We also need people who are prepared to take responsibility for their own careers and their passions. Be ambitious! Plan your career. Get some professional development. Sometimes you’ve got to make your own future.’ (See below for more thoughts from Tracey about how health care providers can prepare for changes in PHC.) 



As a direct result of the SMT’s recommendations, the May 2023 Federal Budget will fund more flexible multidisciplinary team-based PHC models and the National Scope of Practice Review, but that’s not all. The government will also be aiming to expand the PHC nursing workforce. Five hundred previously registered nurses will be supported to return to the workforce, and APNA will be working with the Department of Health and Aged Care to engage 6,000 nursing students in PHC clinical placements around the country.  

Tracey Johnson is excited about the additional government funding that is going towards multidisciplinary team-based care. ‘There’s a real momentum building behind the multidisciplinary care model as part of the solution to an aging and increasingly chronic population,’ she says. ‘Simply training more doctors is not the answer. Doctors take a long time to train and we need more care now. So, we must turn to other members of the team. You’ve got to be able to work with others. I really like the acronym for TEAM: Together Everyone Achieves More!’  

Karen Booth welcomes the budget’s new measures, saying that they lay the groundwork for lasting and sustainable structural change for nurses working in the PHC system. ‘Everyone realises that the current system isn't working. This budget takes some strategic first steps to strengthening our health system and making it fit for purpose. It addresses the growing nursing shortages in PHC. We will see more nurses hired where they are needed, and we’ll see more nurses utilised to their full potential.’ 

However, Karen is emphatic that we should see the budget’s announcements not as an end-point but more like ‘firing the starting gun’ of a long PHC reform process. She agrees that a good change-management process will be the key to success. ‘We need to plan these changes carefully so that we can strengthen the overall health system in the long term,’ she says. ‘Don’t worry – there will be more to come. This is just the starting point.’ 



1 Australian Government, Strengthening Medicare Taskforce report, Department of Health and Aged Care website, December 2022, accessed 22 May 2023. 

2 Australian Government, Budget overview: stronger foundations for a better future, May 2023, accessed 22 May 2023. 

3 Australian Government, Department of Health and Aged Care (DOHAC), Summary of strengthening Medicare policies, DOHAC website, 28 April 2023, accessed 22 May 2023.  

4 APNA, APNA member update: The 2023/24 Federal Budget – what it means for you, APNA website, May 2023, accessed 22 May 2023. 

5 Kim Poyner, Riwka Hagen, Chris Smeed (hosts), ‘Ensuring continuity of care: a look at voluntary patient enrolment in primary care’ [podcast], Medicubes, accessed 22 May 2023. 


Tracey Johnson’s tips on preparing for change in PHC  

With the new package of government measures to strengthen primary health care, there are some major changes on the way for the sector. Inala Primary Care CEO Tracey Johnson has some advice for health care providers about how to prepare for the transition.  

1. Attitude  

We need to develop a team-based mindset. The patient should always be at the centre of care. Care teams should determine with the patient what they need, and how the team might collectively respond to those needs. This includes the patient and their carer(s) too. What can they do to manage their own health care needs? To avoid the fragmentation of care, we each need to determine what our roles and responsibilities are in advocating for the patient, and advocating for change where needed.  

2. New skills  

We need to work out where we can get more value from our health care system. Workforce skills around change management, leadership, clinical governance, co-design and patient engagement will be crucial. All of these things are actually lacking in the core curriculum of so many of our health disciplines. And yet for us to shift the dial, and become more patient-centred and team-based, we need all of these skills. We also need evaluation skills, and data collection and analysis skills. Many nurses are very people-oriented, but when it comes to articulating how their work adds value to the health care system, they can have trouble quantifying their role. This is actually a real weakness of skill in our nursing workforce. So gaining some of those skills would be a real advantage, and would better enable nurses to advocate for change.  

3. Sustainability  

We need to look after ourselves and one another. This includes managing our own resilience and self-preservation, and dealing with conflict. Change is hard and it requires perseverance. It’s important that we can sustain our efforts without burning out and becoming jaded and cynical. Kindness to self and others and being willing to forgive mistakes is central to that. 

4. Long-term vision  

We need to look at the data and respond to that data proactively. Start asking ‘What are our patient populations? What do they need? How are they trending over time?’ Once we’ve gone through the transformative change process, it will be important to work out how we can maintain the incremental changes required for quality improvement over the long term.  

5. Extended teams  

We need to take a step back and understand the big picture. We need to develop partnerships and collaborations, and develop the governance around those partnerships. This is an entire discipline in and of itself. In addition to our health care teams, we need health care neighbourhoods. These are the extended teams we need to think about more.  

6. Initiative  

We need people who are prepared to take responsibility for their own careers and their passions. Being humble as we go about doing that will enable us to hear more, learn more and prepare more. Take some responsibility, get some professional development and take some risks all the while reflecting on what you learn as you go! 


Multidisciplinary care at Inala Primary Care, Brisbane 

Inala Primary Care is a charitable multidisciplinary teaching and research active general practice in Brisbane. The team includes GPs, a large team of nurses, non-dispensing pharmacists, allied health practitioners and a visiting social worker. This practice exemplifies the team-based primary health care model that we can expect to see more of in the future. We asked nurses Jacinta McGovern and Rebecca Burgess about their roles as part of the team. 

Primary Times: What are your roles at Inala Primary Care? 

Jacinta McGovern: I’m a registered nurse and I specialise in chronic disease care. I treat patients of all ages and with all kinds of chronic disease. Some have complex co-morbidities. It’s also my job to coordinate care with other disciplines onsite and with hospitals, and to educate patients about their health and wellbeing. 

Rebecca Burgess: I’m an enrolled nurse and I work in the treatment room. My daily tasks are wound care, immunisation, ECGs, taking vital signs, baby immunisation and so forth. Occasionally I’m involved with triage and urgent care, but this is under supervision of the registered nurses.  

PT: Which other disciplines do you work closely with? 

RB: I work closely with the GPs, helping them find what they need in the treatment room. 

JM: A podiatrist, Matt Christie, works here part-time. He’s a lower limb specialist and we can refer our patients to him. This is often necessary for patients with diabetes. Having Matt in the treatment room is an absolute bonus. 

RB: When Matt is here, he and I share the treatment room and the care we provide often overlaps. Most of his podiatry patients have high risk factors (associated with chronic disease) for developing wounds on their lower legs. Quite frequently, he’ll notice a wound on a patient’s foot or leg, and he’ll ask me to dress it. He might also refer the patient to a doctor for antibiotics. It’s an efficient model: patients are getting immediate medical treatment in addition to their podiatry treatment. If they hadn’t come in for podiatry, the wound might have gone untreated. 

JM: I’ll often refer my patients, via the doctor, to see the social worker. Many of them are struggling with social issues, such as insecure housing, and that can have a severe impact on their health. Many of them are lonely too. Having a social worker with mental health certification onsite is brilliant. 

I’ll also participate in shared consultations with a GP and a pharmacist. This is often necessary when a patient begins a new medication. The pharmacist will advise how to obtain the medication, and I’ll demonstrate how to use it. The pharmacists also go through the patients’ discharge summaries from hospitals, receive incoming calls from community pharmacy for repeat scripts and they do medication reviews. This helps to avoid adverse effects and reduces the chance of hospital rebounds. 

PT: What are the other benefits to multidisciplinary care? 

RB: I’m learning so much about foot conditions from Matt and about medications from the pharmacists. I overhear a lot information and it’s all relevant to my practice. I really enjoy the days when Matt’s here. 

JM: The care we provide here is more holistic than other places I’ve worked. But it’s also a sign of the times: an aging population and higher rates of chronic disease means that the only way to provide comprehensive care is with a multidisciplinary team. 


Team-based care at the Victorian Aboriginal Health Service, Melbourne 

The primary health care (PHC) sector is moving towards more flexible multidisciplinary care models; however, some PHC organisations have been operating effective team-based models for decades. Aboriginal Community Controlled Health Organisations (ACCHOs) are run by locally elected boards of directors (Aboriginal community members) to deliver comprehensive and culturally appropriate PHC to their local Aboriginal communities. Deepika Kaushik is a clinical nurse team leader at the Victorian Aboriginal Health Service (VAHS), Australia’s second longest running ACCHO (after the Redfern Aboriginal Medical Service, Sydney). We caught up with Deepika to find out about the multidisciplinary model at VAHS.  

Primary Times: Tell us about the different disciplines and teams at VAHS. 

Deepika Kaushik: I work in a medical team alongside Aboriginal health practitioners, Aboriginal health workers, GPs and other nurses. There’s also a women’s and children’s unit, with midwives, GPs and visiting paediatricians. The community programs team includes allied health workers, such as podiatrists, dieticians and physiotherapists. Integrated Team Care health workers care for people with complex chronic conditions. A team of counsellors, psychologists and psychiatrists provide a family counselling service. We have onsite and visiting specialists (e.g., respiratory specialist, dermatologist, ophthalmologist). Some specialists are funded through the Rural Workforce Agency Victoria, and some donate their time. And we have an onsite pharmacy. Most medicines are provided either free or at a very low cost. 

PT: What roles do nurses play? 

DK: There are nurses in all of the teams. I specialise in chronic disease and wound management. Other nurses are specialists in sexual health, mental health, or drugs and alcohol. The community nurses visit the community Elders, as well as people who are very unwell. 

PT: Who are the team leaders? 

DK: It’s mostly an Aboriginal health practitioner-led model. We nurses and the GPs are just their assistants a lot of the time! Due to workforce shortages, however, it’s not always possible to have an Aboriginal health practitioner leading. For example, I’m a team leader, but I’m not Aboriginal. But I’ve been working at VAHS for nearly 9 years, and I’ve gradually gained the community’s trust. When I first started, I was mentored by an Aboriginal health worker who was a respected member of the community, and she taught me a lot about cultural safety. 

PT: How does your role compare to working in mainstream general practice? 

DK: The work here is very care-driven. Working in mainstream general practice, I didn’t get to spend as much time with patients. I do a lot of case management and care coordination here and the variety of work means that we learn a lot, working with other disciplines. We get to work to a broader scope, and we encourage that in all our nurses, with training and supervision. We get funding through various programs, so we’re not relying fully on the Medicare system, and the organisation is not profit-focused. 

PT: How does the multidisciplinary model work in practice? 

DK: We work holistically. Our model provides really comprehensive care and also maintains clients’ cultural safety. Good communication is key to providing continuous care and to avoiding duplication of care. This involves case conferences, face-to-face discussions, referrals, emails and messages via the organisation’s software. We also back up these measures with phone calls, to ensure that nothing gets missed. Care is coordinated on a case-by-case basis. 

PT: Do you enjoy the teamwork? 

DK: I work in one of the best teams! We are all passionate about health care and we all try to provide the best care that we can. 








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