Ask Proactive – How does an interdisciplinary team contribute to effective discharge planning in healthcare?

How does an interdisciplinary team contribute to effective discharge planning in healthcare?

A:

Discharge planning is a critical process in healthcare, involving an interdisciplinary team to ensure a smooth transition from one care setting to another. Here are the roles typically involved in discharge planning and their responsibilities:

1. Physician/Primary Care Provider (PCP)

• • • • Assess patient’s medical condition and readiness for discharge.
      • Provide medical orders and necessary prescriptions.
      • Communicate with the patient and family about the discharge plan.

2. Nurse

• • • • Coordinate the discharge plan.
      • Educate the patient and family about care needs post-discharge including, but not limited to medication management.
      • Ensure that necessary medical supplies and equipment are arranged in coordination with Social Services and the Case Manager.
      • In coordination with social services and the case manager, conduct a follow-up call 24-48 hours after discharge to determine resident received all necessary equipment and prescriptions, and answer any questions they may have to minimize risk of hospital readmission/ER visit.

3. Social Services

• • • • Assess the patient’s social needs and support systems.
      • Facilitate access to community resources and services based on patient specific needs.
      • Provide counseling and support to the patient and family.
      • Coordinate with nursing to ensure necessary medical supplies, equipment are arranged, in addition to ordered home health/outpatient services are
      • In coordination with nursing and the case manager, conduct a follow-up call 24-48 hours after discharge to determine all necessary equipment and prescriptions were received, and answer any questions they may have to minimize risk of hospital readmission/ER visit.

4. Physical Therapist (PT)

• • • • Assess the patient’s mobility and physical therapy needs. Recommend adaptive devices as needed.
      • Develop a home exercise program if needed.
      • Schedule a home assessment visit when indicated based on facility policy
      • Address potential risks and barriers to safe mobility at home and provide fall risk reduction interventions when warranted
      • Coordinate with home health or outpatient services for continued therapy.

5. Occupational Therapist (OT)

• • • • Evaluate the patient’s ability to perform daily activities including ADL/IADLs. Assess the cognitive level for best ability to function and to guide recommendations on care routines and levels of recommended caregiver assistance.
      • Recommend any needed home modifications and/or adaptive equipment.
      • Educate the patient and family on strategies to improve independence and safety.

6. Speech-Language Pathologist (SLP)

• • • • Assess communication abilities and swallowing disorders.
      • Develop a plan for speech and language therapy if needed.
      • Provide dietary recommendations for swallowing difficulties.
      • Educate the patient and family on strategies to improve functional cognitive-communication skills

7. Pharmacist

• • • • Review and reconcile medications.
      • Provide medication education to the patient and family.
      • Ensure that prescriptions are filled and available for discharge.

8. Dietitian/Nutritionist

• • • • Assess nutritional needs and provide dietary recommendations.
      • Develop a nutrition plan tailored to the patient’s medical condition.
      • Educate the patient and family on dietary management.

9. Case Manager

• • • • Oversee and coordinate the discharge planning process.
      • Coordinate with insurance and healthcare providers.
      • Ensure continuity of care by arranging follow-up appointments and services.
      • In coordination with nursing and social services, conduct a follow-up call 24-48 hours after discharge to determine all necessary equipment and prescriptions were received, and answer any questions they may have to minimize risk of hospital readmission/ER visit.

10. Patient and Family

• • • • Participate actively in the discharge planning process.
      • Communicate any concerns or preferences to the healthcare team.
      • Follow the discharge plan and attend follow-up appointments.
      • Monitor the patient’s condition and report any changes.

This interdisciplinary approach ensures that all aspects of a patient’s care are addressed, promoting better outcomes, and reducing the likelihood of readmissions.

Sarah Becker RN, RAC-CT, DNS-CT, QCP
Clinical Consultant

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