Multidisciplinary

Case Conferencing

Understanding A Multidisciplinary Case Conference (MDCC)

A Multidisciplinary Case Conference (MDCC) is a structured, collaborative meeting between a

General Practitioner (GP) and Allied Health professionals from diverse fields, who come together

to support the comprehensive management of patients with chronic or complex conditions.


The purpose of the MDCC is to share expertise across disciplines to ensure the patient

receives holistic, varied and tailored advice without needing to attend separate Allied

Health appointments to obtain this advice.


Without being a direct treating provider, the participating Allied professionals provide input into the

GP Chronic Condition Management Plan (GPCCMP) by helping to determine what type of care may be most

beneficial to the patient moving forward. The GP acts as the central access point, coordinating and relaying

specialist Allied Health recommendations directly to the patient. As a result, patients receive more comprehensive care planning, improved condition management, and the benefits of multidisciplinary input, even when Allied Health professionals are not physically accessible in their community. 


During the conference, the GP and Allied Health team work together to: 


  • Discuss the patient’s chronic health conditions and overall needs, sharing clinical observations, assessment findings, and relevant background information. This ensures the team forms a complete understanding of the patient’s medical, physical, functional, psychological, and social circumstances. 
  • Share multidisciplinary suggestions for treatment, with each provider contributing recommendations based on their specialised knowledge and therapeutic perspectives. This collaborative process helps identify and prioritise the most effective strategies to improve health outcomes, manage symptoms, prevent the progression of chronic health, reduce hospitalisations, support functional independence, and enhance quality of life. 
  • Share and propose resources, services, and supports that may assist the GP in managing the patient’s care. These may include Allied Health interventions, community programs, psychosocial supports, educational materials, specialist referrals, or assistive technologies that may improve patient function and independence. 
  • Develop a unified and comprehensive treatment plan that reflects the collective expertise of all involved disciplines. This plan outlines key clinical priorities, targeted interventions, and agreed-upon strategies to address the patient’s multidisciplinary needs in a coordinated manner. 
  • Provide structured goals and clearly defined actions for future care. These goals are designed to guide intervention, and support continuous evaluation of the patient’s health and wellbeing. 


Overall, the multidisciplinary case conference enables a cohesive, patient‑centred approach to chronic condition management by improving communication, reducing service fragmentation, and ensuring that all aspects of the patient’s care are considered and addressed through a unified, collaborative discussion and plan. 


Across every stage of life, health needs can become complex—not just medically, but functionally, psychologically, and socially. Multidisciplinary case conferencing brings all of these threads together. It is a structured, evidence‑based model where GPs and Allied Health professionals collaborate in real time to build a complete picture of a patient’s health, ensuring care is not just coordinated, but genuinely connected. 


By weaving together diverse expertise, MDCCs help identify gaps, streamline interventions, and create unified care plans that evolve with the patient through every age and stage. It reduces fragmentation, supports early identification of risks, and ultimately improves long‑term outcomes by making sure every patient receives the right care, at the right time, from the right team. 


At its core, multidisciplinary case conferencing is about transforming isolated insights into shared wisdom—so people can live well, age well, and feel supported by a team that truly sees the whole person.



Purpose & Benefits of a Multidisciplinary case conference

The purpose of a Multidisciplinary Case Conference (MDCC) is to enhance the quality, coordination, and effectiveness of care for patients with chronic or complex health needs. This includes: 


Supporting the GP in patient care 
The MDCC provides the GP with comprehensive, discipline‑specific insights that enhance their understanding of the patient’s chronic health conditions, functional limitations, psychosocial factors, and day‑to‑day challenges. By discussing patient conditions with Allied Health professionals the conference enables the GP to make more informed decisions, refine the GP Chronic Condition Management Plan (GPCCMP), and deliver care that is better aligned with the patient’s evolving needs. This collaborative environment ensures the GP is supported with accurate, current, and clinically relevant Allied Health information. 


Enhancing patient outcomes 
By integrating multiple perspectives and developing a cohesive, goal‑directed plan, the MDCC strengthens the overall quality of care. The patient benefits from a more holistic and proactive approach that combines medical, functional, psychological, and lifestyle factors which may be contributing to their chronic condition. Improved coordination and shared expertise lead to more effective interventions, earlier identification of issues, and better long‑term health outcomes. 

MDCC Format & Process

The MDCC follows a structured format. The GP begins by presenting the patient’s history, diagnoses, investigations, medications and current management, supported by shared medical records. The GP then outlines key concerns and poses focused questions to Allied participants. A multidisciplinary discussion follows, where each professional contributes clinical observations, recommendations and relevant resources. Agreed actions and treatment strategies are summarised into a clear report to guide future care.


The process includes patient consent, coordination of participant details and scheduling of the conference. During the conference, cases are timed and recorded using AI transcription. Afterward, the GP receives a written patient report summarising the MDCC which they then use to discuss the suggestions made with the patient. The GP will also receive a billing spreadsheet, ensuring documentation and compliance with Medicare requirements.

Sharing Resources

Share resources and services 

The MDCCs provide an open forum where the GP and Allied Health professionals can share information about treatment, as well as relevant resources, programs, and services that may improve the patient’s care. Each discipline has unique knowledge of supports available within their field—such as therapeutic programs, community initiatives, specialist pathways, educational tools, assistive technologies, or lifestyle‑based interventions—that may not be readily visible to other providers. 


By sharing knowledge of resources during the MDCC, the team is able to: 


  • Increase awareness of available supports 
    Providers contribute insights into services that may benefit the patient, including public health programs, relevant education programs, rehabilitation services, mental health supports, and community exercise groups. 
  • Guide the GP in identifying appropriate referrals 
    The GP gains a clearer understanding of what each service offers, how it aligns with the patient’s goals, and how it can be integrated into the GPCCMP. This helps ensure that limited funded Chronic Condition Plan referrals are targeted, timely, and clinically relevant. 
  • Streamline access to supports 
    Allied Health professionals can offer practical information about eligibility criteria, funding options, wait times, referral requirements, and the scope of each service, making it easier for the GP to coordinate next steps. 
  • Ensure interventions complement one another 
    By discussing services collectively, the team can avoid duplication, assist in prioritising treatment, prevent conflicting recommendations, and ensure each recommended treatment reinforces the broader treatment plan. 

Overall, sharing resources and services during the MDCC strengthens communication, supports efficient planning, and equips the GP with varied tools and knowledge needed to optimise the patient’s care under the GPCCMP.

PROFESSIONAL UPSKILLING

A key purpose of a Multidisciplinary Case Conference (MDCC) is to create a shared learning environment where the GP and Allied Health professionals have the opportunity to expand their knowledge through direct collaboration. Each discipline brings unique clinical insights, practical strategies, and specialised expertise that contribute to an enriched understanding of the patient’s condition. By discussing assessment findings, therapeutic approaches, and management strategies together, all participants gain exposure to perspectives outside their own area of practice.


For the GP, this collaboration provides deeper insight into functional, behavioural, psychological, rehabilitative, and lifestyle based interventions that complement medical treatment. It enhances the GP’s understanding of how Allied Health services fit within the patient’s broader care pathway, and supports more informed decision making when adjusting the GPCCMP or making referrals.


For Allied Health professionals, the MDCC offers valuable understanding of the patient’s medical complexities, diagnostic considerations, pharmacological treatments, and the GP’s clinical priorities. This enables them to refine their suggested interventions, better appreciate the medical context of their work, and tailor their strategies to ensure alignment with the GP’s chronic condition management plan.


Through this exchange of expertise, all members of the care team increase their clinical competence, improve interdisciplinary communication, and develop a more integrated approach to chronic condition management. Ultimately, this shared learning strengthens the quality of care provided, assists all disciplines in appreciating the role, knowledge and expertise of others, and can enhance overall patient outcomes.


Frequently Asked Questions (MDCC) - GP

  • What is an MDCC?

    A multidisciplinary case conference (MDCC) is a structured meeting where a GP

    collaborates with a team of Allied Health professionals to review and plan care for

    patients with chronic or complex health needs.


    The goal is to provide holistic, coordinated, evidence-based care through shared

    expertise.

  • Why participate? – Key Benefits for GPs

    •  Improved clinical insight through direct input from Allied Health disciplines
    • Stronger GPCCMPs, with clearer goals and more targeted and prioritised
    • interventions
    • Enhanced referral quality using real-time advice from the various Allied disciplines
    • Professional development through cross-disciplinary discussions
    • Improved patient outcomes via unified, varied team planning
  • What happens in an MDCC?

    Each case discussion includes:


    1. GP Presentation

    • Medical history, diagnoses, medications
    • Functional, psychological, and social considerations
    • Recent investigations and specialist reports
    • GPCCMP goals and outstanding challenges

    2. Identification of Key Needs

    • GP outlines questions for specific Allied Health disciplines
    • Priorities for intervention are clarified

    3. Multidisciplinary Discussion

    • Allied Health may provide:
    • Assessment findings and observations
    • Therapy recommendations
    • Behaviour-change and self-management strategies
    • Psychosocial considerations
    • Assistive technology or environmental needs
    • Relevant resources or services
  • Which patients are suitable?

    Patients must have a current and valid GP Chronic Condition Management Plan (GPCCMP) in place to be eligible for a MDCC.


    Suitable patients:

    • Have chronic or complex health needs
    • May benefit from the expertise of varied Allied Health providers
    • May have barriers affecting progress or outcomes

    Up to 10 patients can be presented per conference.


    Under the current Medicare guidelines, patients with a GPCCMP are eligible for a MDCC every 3 months if their GP feels it's warranted.

  • What are my responsibilities as the GP?

    Before the meeting:

    • Identify suitable patients
    • Ensure consent is obtained and recorded
    • Provide patient details (Name, DOB, Medicare number, and summary of condition/s) to the coordinator (template is provided)
    • Ensure EMR (Electronic medical record) documentation is up to date and suitable for sharing and discussion in the conference

    During the meeting:

    • Present each case
    • Ask discipline-specific questions
    • Guide priorities for care
    • Confirm clinically appropriate recommendations

    After the meeting:

    • Review the conference report
    • Update the GPCCMP as needed
    • Discuss recommendations with the patient at their next appointment
    • Complete billing through Medicare (template is provided)
  • What support does the Coordinator provide?

    • Information and assistance at any time to the GP
    • Organises meeting logistics and invitations
    • Arranges Allied participants
    • Provides templates, forms and spreadsheets
    • Coordinates the case conference, ensuring timing is satisfied, discussion flows, GP queries are answered, and compliance is achieved
    • Times and records each case discussion (Using Heidi AI scribe), ensuring Medicare requirements are fulfilled
    • Follows up with Allied if further information/documentation/resources are suggested
    • Produces the MDCC Patient Reports for the GP
    • Provides final spreadsheet with full information for GP to complete billing
  • How long does an MDCC take?

    • Usually 20-25 minutes per patient case
    • Full conference of 8-10 patients: Approximately 4 hours
  • What technology is required?

    • Access to patient electronic medical records (EMR)
    • Ability to screen-share via Microsoft Teams
    • Stable internet connection
  • How do MDCCs improve patient outcomes?

    Patient outcomes are improved due to:

    • Holistic consideration and understanding of the patient
    • Contributing factors, in addition to medical (functional/physical, psychological and social) are better understood, so treatment plans can reflect the complete picture of the patient’s health and goals
    • More effective use of limited GPCCMP referrals. Many patients with chronic conditions see multiple providers. Without coordination, visits can overlap.
    • Higher-quality, proactive chronic condition management
    • Receiving coordinated advice. Patients feel supported by a whole team, they are more likely to follow through on recommendations, and their confidence in the GPCCMP can increase
  • How do MDCCs benefit the GP?

    MDCCs give GPs direct access to discipline-specific perspectives that would otherwise take multiple appointments, letters, or referrals to obtain.


    This deeper insight may help the GP to:

    • Understand and address the patient’s functional, psychological, and social complexities, as well as their medical needs
    • Clarify the underlying causes behind stalled progress
    • Receive real-time feedback and suggestions from a capable team of Allied professionals
    • Reduce diagnostic uncertainty due to additional feedback from Allied participants
    • Recognise where they can medically take further action, which they may not have had the time or foresight to do in a limited 15min regular appointment
  • What is the format of a MDCC?

    1. GP Presentation of Patient History, Diagnosis, and Current Treatment 

    The MDCC begins with the GP presenting a comprehensive overview of the patient’s medical background. This includes relevant history, diagnoses, current symptoms, comorbidities, investigations, medications, social situation, and any recent changes in health status. 

    To support clarity and shared understanding, the GP displays electronic medical records on the shared conference screen, allowing all participants to view assessment data, pathology reports, imaging results, current treatment plans, and past specialist letters. 

    This ensures the foundation for accurate multidisciplinary input. 


    2. GP Identifies Care Needs and Poses Specific Questions to Allied Professionals 

    Following the presentation of the patient history, the GP outlines the key care needs, challenges, or concerns requiring multidisciplinary input. 

    The GP may ask targeted questions directed at specific Allied Health disciplines—for example regarding functional capacity, mobility, pain, psychosocial barriers, lifestyle factors, rehabilitation potential, physical or technical aids, or recommended interventions. 

     

    3. Multidisciplinary Discussion Among All Participants 

    A structured discussion is then held between the GP and all Allied Health participants. Each professional contributes insights based on their assessments, expertise, and scope of practice. 


    This discussion may include: 

    • clinical observations and functional assessments 
    • therapeutic recommendations and intervention options 
    • behaviour‑change or self‑management strategies 
    • psychosocial considerations and supports 
    • environmental or assistive technology needs 
    • risks, barriers, and priority areas for intervention 

    Allied Health professionals may also share discipline‑specific resources and services, such as community support, therapy pathways, patient education materials, funding options, or specialist referral avenues. 


    This open exchange ensures a rich, holistic discussion of the patient’s needs and promotes optimal care planning. 


    4. Summary of Agreed Care and Treatment Recommendations for Patient Report 

    At the conclusion of the discussion, the GP and Allied Health team collaboratively summarise the agreed‑upon suggested care actions, recommendations, and treatment strategies. 

    These recommendations, with the use of AI Transcribe, are translated into a clear, concise summary suitable for providing the GP with a written report from the conference to discuss with the patient, outlining goals, referrals, and next steps. 


    The final Report ensures the patient's future care is guided by a unified, multidisciplinary plan.

  • What steps are involved in the process of a MDCC?

    Steps of the process 


    Before the MDCC


    1. Coordinator provides GP with names and professions of participating Allied Health. 


    2. GP identifies 8-10 patients with a current GPCCMP in place, to present and discuss at the MDCC. 


    3. GP’s Admin (or GP) contacts patients for their consent to have their case discussed at the MDCC. (Coordinator to provide a consent form you can email, or a template for a phone consent). Consent is formally recorded, saved to the patient file, and shared with the Coordinator. NB: Patient Consents must be kept on file by the GP and by the Coordinator. 


    4. GP’s Admin provides to the Coordinator: 

    • Copy of completed consent forms 
    • Patient names, DOB, medicare number, and summary of chronic condition/s (template spreadsheet provided by Coordinator) 

    5. Coordinator sets up a Teams meeting for the MDCC, invites participants through link. 


    On the day of the MDCC 

    • Allied participants (and Coordinator) join the meeting from our conference room in Mullumbimby Health Centre. 
    • The remote GP joins the meeting online via Teams Conference. The GP shares screen so the Allied can see the patient file and information presented. 
    • Coordinator times and records each Case Conference, using AI Transcribe, guiding the group to fulfil requirements. 

    The day after the MDCC 


    The Coordinator provides the GP with: 

    • Individual Patient reports from the conference. NB: Patient reports must be kept by the GP on patient files, and by the Allied participants on patient files.
    • Spreadsheet for GP for medicare billing 

     

  • Do the Allied Participants need to have a pre-existing relationship with the patient?

    No.  


    The Allied professionals provide input into the Chronic Condition Management Plan without being a direct treating provider by contributing knowledge and suggestions, and helping to determine what type of care may be most beneficial moving forward. 


    This approach helps bridge service gaps by allowing the GP to act as the central access point, coordinating and relaying specialist allied health recommendations directly to the patient.

  • Can a Practice Nurse participate in an MDCC?

    A Nurse / Practice Nurse may participate in the MDCC if their input is needed, but they cannot claim an MBS item for their participation. 

Frequently Asked Questions (MDCC) - Patient

  • What is a Multidisciplinary Case Conference (MDCC)?

    A multidisciplinary case conference is a coordinated meeting where your GP and a team of Allied Health professionals discuss your chronic or complex health conditions. The aim is to combine expertise from different disciplines so your care is holistic, well coordinated and based on best practice evidence.

  • Why is an MDCC held?

    MDCCs are held to improve the quality, coordination and effectiveness of your care.


    By bringing your GP together with multiple Allied Health practitioners, your GP can make more informed decisions and update your GP Chronic Condition Management Plan (GPCCMP) using accurate, real time clinical insights from various disciplines.

  • Do I need to attend the MDCC?

    No.


    You are not required to attend. The meeting is a professional case discussion between your GP and Allied Health professionals.

  • Does it cost me anything?

    No.


    There is no cost to you. The MDCC is funded through Medicare as part of GP chronic condition management processes.

  • What happens during the MDCC?

    During the conference, your GP and Allied Health team will:


    • Discuss your medical history, diagnoses, symptoms and overall needs.
    • Share assessment findings and clinical observations.
    • Provide treatment suggestions based on their area of expertise.
    • Suggest useful resources, programs and services.
    • Develop a unified treatment plan with clear goals and actions.
    • Identify next steps, referrals and review timelines.

    This ensures your future care follows a cohesive, multidisciplinary approach.

  • Who participates in an MDCC?

    Participants include your GP and usually a number of Allied Health professionals on behalf of their profession, such as:


    • Physiotherapist
    • Psychologist
    • Dietitian / Diabetes Educator
    • Osteopath / Chiropractor
    • Exercise Physiologist
    • Nurse
    • Occupational Therapist
    • Other Allied Health professionals relevant to your care

    You can request participating practitioner names and designations during the consent process.

  • What are the benefits for me as a patient?

    MDCCs benefit the patient by:

    • Providing a single organised health plan covering medical, functional, psychological and social factors
    • Improving symptom management, function, preventative care, and quality of life
    • Supporting early identification of issues or risks
    • Ensuring referrals and Care Plan visits are used effectively
    • Providing a clearer, inclusive pathway for ongoing care
  • Why is my case being discussed?

    Your GP wants to ensure you receive the best possible care. By discussing your care with a number of Allied Health participants on behalf of their profession, an MDCC helps your GP:

    • Consider all aspects of your health, not only medical
    • Strengthen your GP Chronic Condition Management Plan (GPCCMP)
    • Prioritise and coordinate your care more effectively
  • What do they talk about?

    During the MDCC, your team discusses:


    • Your medical history and chronic conditions
    • Current symptoms and functional challenges
    • Assessments and clinical findings
    • Treatment options and strategies
    • Lifestyle, psychological and social factors
    • Community supports and services
    • Recommendations for referrals
    • Your goals and next steps

    This ensures your care is holistic and well coordinated.

  • How does an MDCC benefit me?

    An MDCC helps you by:


    • Creating a clearer, overall, more concise care plan
    • Reducing duplicated or conflicting advice
    • Supporting earlier identification of issues
    • Ensuring your funded Care Plan visits are used effectively
    • Improving your long term health outcomes
    • Reducing hospitalisations
    • Identifying any gaps in care
  • What happens after the MDCC?

    Your GP will:


    • Review the MDCC summary
    • Discuss recommendations with you at your next appointment
    • Update your GP Chronic Care Management Plan if needed
    • Arrange any new referrals
    • Plan follow up and monitoring
  • Why do I need to give consent?

    Your health information is private.


    Your GP needs your permission to discuss your case with other practitioners. Consent can be given:

    • Over the phone
    • Via a written form or email

    Your consent is stored securely by your GP and the MDCC coordinator.

  • How is my information protected?

    Only relevant health information is shared with participating practitioners.


    All information remains confidential and is handled according to Australian Privacy Principles.

  • Who can I contact if I have questions?

    If you have any questions about the MDCC, please contact your GP, via Reception staff.