Community Multi-Disciplinary Teams (CMDTs)

Community Multi-Disciplinary Teams (CMDTs)

Local Community Multi-Disciplinary Teams (CMDTs)

Six Community Multi-Disciplinary Teams (CMDTs) have been established across all of Southwark and Lambeth, and each team has a member from each of our participating partner organisations. CMDTs exist to support care managers in managing the most complex cases, and to lead improvement in the quality and coordination of care on their patch.

Each CMDT consist of the following members:

  • Community Matrons
  • Integrated Care managers from general practice
  • A Community Therapy lead
  • A senior Social Worker for Older People
  • A senior practitioner from the Community Mental Health Teams for older people
  • A Consultant Geriatrician with experience in community and hospital care for older people

Each CMDT has a chair who is either a local general practitioner or nurse specialist for older people working in a local practice.

How do local people access the service?

The care managers, with your consent, will take your case to the CMDT. They will do this if they feel you are not getting the support that you or they need in order to deliver your care plan successfully.

Information for local people on how the service works

Your care manager (community matron or integrated care manager from your GP practice) will present your case to the team. The CMDT will then agree an action plan that is intended to improve the delivery of your care. It will review whether agreed actions have taken place at its future meetings.

Information for professionals providing the service

The CMDT meets on average twice a month. All members can nominate patient cases that they think would benefit from a multi disciplinary discussion. All CMDT members are responsible for both recommending and completing actions that will improve the effectiveness of the case management plan. The CMDT members will also check if these actions have been delivered.

CMDT members should share examples of good practice as well as information about local organisations that might be able to assist with the effectiveness of case management plans.

From time to time the CMDT will use these discussions to confirm how services might be improved in the future for other local people.

The CMDT will also review their own performance at their governance meeting. These take place six times a year.

Detailed guidance is available here:

Materials that have been developed and collected to support the CMDTs are as follows:

SBAR – tool to enable professionals to summarise a patient’s case and consider how to set out recommendations for the future.

PEACE Document – A document to assist professionals to discuss end of life care with patients and their carers or relatives and document a plan that reflects the patient’s wishes. PEACE doc

Amber Care Bundle – a tool to assist the delivery of palliative care, particularly useful to manage times when the patient needs additional support. Attach 13a ‘What is AMBER’ and AMBER pathway in community settings

Riverside – The Southwark Information, Advice and Access service.
Open 7 days a week, 8am-8pm Tel: 0345 155 9033

Sanctuary – Provides Floating Housing support and other housing advice. Tel: 020 7231 7083

Southwark Circle – A membership organisation that provides on-demand help with life’s practical tasks through neighbourhood helpers.
Tel: 0800 112 3441