The interdisciplinary team (IDT), at a minimum, must include the:

  • CRS counselor;
  • participant;
  • participant’s representative or advocate (if applicable);
  • professional staff appropriate to the participant’s needs;
  • professional staff currently providing services or planned to provide services, provider case manager; and
  • any community resources such as family members, friends, or people invited by the participant, and community resource providers.

The Interdisciplinary team meeting is also known as a medical team conference and can occur with or without the participant or family member. The expectation is to always include the participant, family member or both, unless extenuating circumstances prevents them from attending. Attendance and participation in the IDT meetings by such IDT members must be documented. Professionals must add their credentials to the signatures.

For example, if a participant is experiencing health problems, their nurse would attend the IDT meeting, or the participant may ask their best friend to participate in the IDT meeting.

The IDT process is designed to allow team members to review and discuss information and make recommendations that are relevant to the participant’s needs. The IDT reaches decisions as a team, rather than individually, about how best to address the participant’s needs. Everyone involved in the participant’s care must work together to provide a uniform and consistent approach to implementation of the IPP.

  • Meetings formally occur every 30 days to develop and review measurable goals and objectives;
  • review a participant’s progress or lack of progress in attaining the goals and objectives;
  • review the efficacy of the services being provided;
  • determine whether to change the participant’s goals, objectives, and timelines and the persons designated as responsible; and
  • review and assess on-going discharge plan and identify needs.

The CRS counselor, the participant, and the participant’s representative or advocate must be notified in writing of the date, time, and location of all IDT meetings at least one week in advance.

The results of the IDT meeting must be documented in a written report. A copy of the report is provided to the CRS counselor within 10 working days after the meeting. A copy must be made available to the participant or the participant’s representative.

In addition to holding the required meeting every 30 days, the IDT must meet as frequently as prudent and necessary, based on need, to maintain an effective treatment program. Adjustments to the IPP, including discharge planning, are made as necessary. Meetings must provide enough time for the participant to ask questions to ensure the participant or family members understanding of the treatment plan.