Roles of the Multidisciplinary Team in Discharge Planning from Hospital
Introduction[edit | edit source]
Successful discharge planning has positive implications for patients and healthcare staff. It reduces the hospital readmission rate at 1 and 3 months, reduces length of stay in hospital, increases the chance of patients returning to the same hospital, increases patient satisfaction and improves patient flow through the hospital.  This reduces the risk of elective procedures being cancelled or patients being held in emergency departments or waiting in corridors. Moreover, by reducing length of stay in hospital there is reduced risk of hospital acquired infections, medication errors, thrombotic events, pressure ulcers, cognitive or functional decline.
Multidisciplinary collaboration promotes effective discharge planning. In order to have successful multidisciplinary team (MDT) discharge planning, there needs to be communication, coordination and collaboration between MDT members, understanding each disciplines roles, as well as patient involvement.
Roles of the Multidisciplinary Team[edit | edit source]
Physiotherapist[edit | edit source]
- Identifying current physical and mobility status. 
- Ascertaining patients goals. 
- Collecting patients social history and home set up.
- Creating ongoing treatment plan. 
- Management advice. 
- Equipment / walking aid prescription and provision.
- Balance and falls assessment and onward referrals.
- Participate in family meetings.
- Training for families or carers. 
- Community referrals.
Occupational Therapist[edit | edit source]
- Assess a patient’s level of function, including transfers/mobility, cognition and activities of daily living, and provide therapy to help them to reach their full potential.
- Prescribe assistive equipment or environment modifications.
- Gather information on patients home environment and previous level of function.
- Collaborative goal setting and problem solving.
- May need to organize family meetings. 
- Provide functional and psycho-emotional discharge and care plans to patients and their caregivers. 
Speech and Language Therapist[edit | edit source]
- Assess communication and swallowing disorders.
- Advise on management of the findings.
- Liaise with the MDT regarding the patients’ ability to understand information and express their wishes regarding discharge planning.
- Create goals, treatment plan and follow up care, and share these with the patient, their family / carers and the MDT. 
- Onward referrals. 
- May need to organize family meetings. 
Doctor[edit | edit source]
- Refer patients to other members of the multidisciplinary team as required. 
- Refer patients to other specialties as required. 
- Ensure patients can follow discharge instructions.
- Communicate with patient and family regarding estimated discharge date and answer any questions.
- Schedule any required tests or procedures early to prevent delays. 
- Deem when the patient is medically fit for discharge.
- Prescribe medicines for discharge.
- Complete discharge summary.
Nurse[edit | edit source]
- Start planning early; planning can be aided by screening tools, risk assessment or care pathway.
- Identify patients with complex discharge needs. 
- Identify who is taking the role of discharge coordinator, as it is different between hospitals/wards. 
- Ongoing review of clinical management plan. 
- Communication with patient and their family. 
- Use a discharge checklist 24-48 hours before transfer/ discharge. 
- Arrange and partake in multidisciplinary meetings. 
- District Nurse referrals. 
- Foster understanding between the MDT of the different roles to improve accountability and referral processes. 
- Arrange patient transport. 
Discharge Coordinator[edit | edit source]
- Lead in planning and coordination of patient discharge. 
- Ensure the clinical, social and care needs of a patient have been assessed and met. 
- Establishing patient and family expectations. 
- Educate the MDT to improve understanding of each disciplines roles and responsibilities in discharge planning. 
- Share knowledge of available services in the community or at home. 
Social Worker[edit | edit source]
- Assess the patients’ needs as well as their home and financial circumstances. 
- Arrange a package of care if required. 
- May act as a key worker or case manager. 
- Involvement for elderly patients with more complex cases or if there are difficulties with discharge destination placing. 
- Discharge planning policy making. 
- Patient and family counseling and advocacy .
- Supporting strategies for community reintegration. 
Pharmacist[edit | edit source]
- Giving pharmacotherapy recommendations .
- Identifying and correcting discharge medication discrepancies. 
- Dispensing discharge medicines. 
- Teaching patients and their caregivers about the medicines. 
Psychologist[edit | edit source]
- Assessment of patient’s needs, for symptom stabilization and treatment planning. 
- Liaison with patients’ family. 
- Referral to community services. 
- Utilizing published discharge planning checklists. 
Dietitian[edit | edit source]
- Identifying patients at risk for nutrition problems or who may require more support. 
- Referrals to community dietitian, either in a clinic or for home visits. 
- Prescribing oral nutritional supplements for discharge.
- Education for meeting nutritional needs at home, including meal delivery programs. 
Conclusion[edit | edit source]
Each discipline has a wide scope of skills they can contribute to discharge planning, and there may be cross over between some roles and responsibilities. Therefore, it is essential for clear communication, organisation and transparency between the MDT, in order to ensure best practice discharge planning for the patient . 
Example case study of MDT working:
Resources[edit | edit source]
References[edit | edit source]
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