RESUMO
Family physicians care for large populations suffering from illnesses which are influenced by social, emotional and family factors. We present a program based on the application of a comprehensive care model in the Kupat Holim clinic and the integration of an interdisciplinary, interagency treatment team in which the focus of intervention is the clinical responsibility of the family physician. The social worker from the neighborhood social service agency and the psychiatrist from the regional mental health clinic participate as integral members of the staff. A broad patient assessment, including identification of clinical psychosocial components and interagency coordination, permits the family physician to involve the other staff members. This article is based on a survey of approximately 100 cases, 70 of which were referred to the clinic social worker for assessment and treatment, while 30 were discussed at bi-monthly consultations in which the clinic staff (family physicians and nurse), psychiatrist and psychiatric social worker, participated. It should be noted that most patients referred to the interdisciplinary forum remained the responsibility of the family physician, which supports the validity of the interagency coordination program.
