Roles of the Multidisciplinary Team in Discharge Planning from Hospital: Difference between revisions

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* Identifying current physical and mobility status. <ref name=":1">Jette DU, Grover L, Keck CP. [https://pubmed.ncbi.nlm.nih.gov/12620087/ A qualitative study of clinical decision making in recommending discharge placement from the acute care setting]. Phys Ther. 2003 Mar;83(3):224-36</ref>
* Identifying current physical and mobility status. <ref name=":1">Jette DU, Grover L, Keck CP. [https://pubmed.ncbi.nlm.nih.gov/12620087/ A qualitative study of clinical decision making in recommending discharge placement from the acute care setting]. Phys Ther. 2003 Mar;83(3):224-36</ref>
* Ascertaining patients goals. <ref name=":1" />
* Ascertaining patients [[Goal Setting in Rehabilitation|goals]]. <ref name=":1" />
* Collecting patients social history and home set up.<ref name=":1" />
* Collecting patients social history and home set up.<ref name=":1" />
* Creating ongoing treatment plan. <ref name=":2">Wright JR, Koch-Hanes T, Cortney C, Lutjens K, Raines K, Shan G, Young D. [https://pubmed.ncbi.nlm.nih.gov/34935968/ Planning for Safe Hospital Discharge by Identifying Patients Likely to Fall After Discharge]. Phys Ther. 2022 Feb 1;102(2)</ref>
* Creating ongoing treatment plan. <ref name=":2">Wright JR, Koch-Hanes T, Cortney C, Lutjens K, Raines K, Shan G, Young D. [https://pubmed.ncbi.nlm.nih.gov/34935968/ Planning for Safe Hospital Discharge by Identifying Patients Likely to Fall After Discharge]. Phys Ther. 2022 Feb 1;102(2)</ref>
* Management advice. <ref name=":2" />
* Management advice. <ref name=":2" />
* Equipment prescription and provision.<ref>WellChild. Appendix B1: Discharge Checklist: child/young person with complex needs/NIV. Available from: https://www.wellchild.org.uk/wp-content/uploads/2021/07/Appendix-B1-Discharge-Checklist-CYP-with-complex-needs-NIV.pdf (Accessed 28/08/22)</ref>
* Equipment prescription and provision.<ref>WellChild. Appendix B1: Discharge Checklist: child/young person with complex needs/NIV. Available from: https://www.wellchild.org.uk/wp-content/uploads/2021/07/Appendix-B1-Discharge-Checklist-CYP-with-complex-needs-NIV.pdf (Accessed 28/08/22)</ref>
* Balance and falls assessment and onwards referrals.<ref name=":2" />
* [[Balance]] and [[falls]] assessment and onwards referrals.<ref name=":2" />
* Participate in family meetings.<ref>Waring J, Marshall F, Bishop S, et al. An ethnographic study of knowledge sharing across the boundaries between care processes, services and organisations: the contributions to ‘safe’ hospital discharge. Southampton (UK): NIHR Journals Library; 2014 Sep. (Health Services and Delivery Research, No. 2.29.) Chapter 4, Discharge planning and care transition. Available from: https://www.ncbi.nlm.nih.gov/books/NBK259993/
* Participate in family meetings.<ref name=":4">Waring J, Marshall F, Bishop S, et al. An ethnographic study of knowledge sharing across the boundaries between care processes, services and organisations: the contributions to ‘safe’ hospital discharge. Southampton (UK): NIHR Journals Library; 2014 Sep. (Health Services and Delivery Research, No. 2.29.) Chapter 4, Discharge planning and care transition. Available from: https://www.ncbi.nlm.nih.gov/books/NBK259993/
 
</ref>
</ref>
* Training for families or carers. <ref name=":3">East London Health & Care Partnership. Roles and responsibilities in discharge planning. xAvailable from:https://www.eastlondonhcp.nhs.uk/downloads/ourplans/Children/Professionals/Discharge%20roles%20and%20responsibilities.pdf (Accessed 28/08/22)</ref>
* Training for families or carers. <ref name=":3">East London Health & Care Partnership. Roles and responsibilities in discharge planning. xAvailable from:https://www.eastlondonhcp.nhs.uk/downloads/ourplans/Children/Professionals/Discharge%20roles%20and%20responsibilities.pdf (Accessed 28/08/22)</ref>
* Community referrals.<ref name=":3" />
* [[Community Based Rehabilitation (CBR)|Community]] referrals.<ref name=":3" />
 
==== Occupational Therapist ====
 
* Assess a patient’s level of function, including transfers/mobility, [[Cognition and Perceptual Disorders|cognition]]  and activities of daily living, and provide therapy to help them to reach their full potential.<ref name=":3" /><ref name=":5">Enhance OT. Discharge Planning OT Services. Available from: https://enhanceot.com.au/discharge-planning-ot-services (Accessed 27/08/2022)</ref>
* Prescribe assistive equipment or environment modifications.<ref name=":5" />
* Gather information on patients home environment and previous level of function.<ref name=":5" />
* Collaborative goal setting and problem solving.<ref name=":5" />
* May need to organize family meetings. <ref name=":4" />
* Provide functional and psycho-emotional discharge and care plans to patients and their caregivers. <ref>Nunes HJ, Queirós PJ. [https://pubmed.ncbi.nlm.nih.gov/28403308/ Patient with stroke: hospital discharge planning, functionality and quality of life.] Rev Bras Enferm. 2017 Apr;70(2):415-423.</ref>
 
==== Speech and Language Therapist ====
 
* Assess communication and swallowing disorders.<ref name=":3" />
* Advise on management of their findings.<ref name=":3" />
* Liaise with the MDT regarding the patients’ ability to understand information and express their wishes regarding discharge planning.<ref name=":6">Aphasia Pathway. Discharge Planning. Available from: http://www.aphasiapathway.com.au/?name=Discharge-planning#:~:text=Speech%20pathologists%20should%20be%20part,with%20the%20receiving%20healthcare%20providers. (Accessed 27/08/2022)</ref>
* Create goals, treatment plan and follow up care, and share these with the patient, their family / carers and the MDT.  <ref name=":6" />
* Onwards referrals. <ref name=":6" />
* May need to organize family meetings. <ref name=":4" />


== Resources  ==
== Resources  ==

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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.[1] [2]  This reduces the risk of elective procedures being cancelled or patient being held in emergency departments or waiting in corridors.[3] Moreover, by reducing length of stay in hospital there is reduced the risk of hospital acquired infections, medication errors, thrombotic events, pressure ulcers, cognitive or functional decline.[3]

Multidisciplinary collaboration promotes effective discharge planning.[4]  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.[5]

Roles of the Multidisciplinary Team[edit | edit source]

Physiotherapist[edit | edit source]

  • Identifying current physical and mobility status. [6]
  • Ascertaining patients goals. [6]
  • Collecting patients social history and home set up.[6]
  • Creating ongoing treatment plan. [7]
  • Management advice. [7]
  • Equipment prescription and provision.[8]
  • Balance and falls assessment and onwards referrals.[7]
  • Participate in family meetings.[9]
  • Training for families or carers. [10]
  • Community referrals.[10]

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.[10][11]
  • Prescribe assistive equipment or environment modifications.[11]
  • Gather information on patients home environment and previous level of function.[11]
  • Collaborative goal setting and problem solving.[11]
  • May need to organize family meetings. [9]
  • Provide functional and psycho-emotional discharge and care plans to patients and their caregivers. [12]

Speech and Language Therapist[edit | edit source]

  • Assess communication and swallowing disorders.[10]
  • Advise on management of their findings.[10]
  • Liaise with the MDT regarding the patients’ ability to understand information and express their wishes regarding discharge planning.[13]
  • Create goals, treatment plan and follow up care, and share these with the patient, their family / carers and the MDT.  [13]
  • Onwards referrals. [13]
  • May need to organize family meetings. [9]

Resources[edit | edit source]

  • bulleted list
  • x

or

  1. numbered list
  2. x

References[edit | edit source]

  1. ↑ Henke RM, Karaca Z, Jackson P, Marder WD, Wong HS. Discharge Planning and Hospital Readmissions. Med Care Res Rev. 2017 Jun;74(3):345-368
  2. ↑ Gonçalves-Bradley DC, Lannin NA, Clemson LM, Cameron ID, Shepperd S. Discharge planning from hospital. Cochrane Database Syst Rev. 2016 Jan 27;2016(1)
  3. ↑ 3.0 3.1 Ibrahim H, Harhara T, Athar S, Nair SC, Kamour AM. Multi-Disciplinary Discharge Coordination Team to Overcome Discharge Barriers and Address the Risk of Delayed Discharges. Risk Manag Healthc Policy. 2022 Feb 2;15:141-149.
  4. ↑ Patel H, Yirdaw E, Yu A, Slater L, Perica K, Pierce RG, Amaro C, Jones CD. Improving Early Discharge Using a Team-Based Structure for Discharge Multidisciplinary Rounds. Prof Case Manag. 2019 Mar/Apr;24(2):83-89.
  5. ↑ Carroll A, Dowling M. Discharge planning: communication, education and patient participation. Br J Nurs. 2007 Jul 26-Aug 8;16(14):882-6
  6. ↑ 6.0 6.1 6.2 Jette DU, Grover L, Keck CP. A qualitative study of clinical decision making in recommending discharge placement from the acute care setting. Phys Ther. 2003 Mar;83(3):224-36
  7. ↑ 7.0 7.1 7.2 Wright JR, Koch-Hanes T, Cortney C, Lutjens K, Raines K, Shan G, Young D. Planning for Safe Hospital Discharge by Identifying Patients Likely to Fall After Discharge. Phys Ther. 2022 Feb 1;102(2)
  8. ↑ WellChild. Appendix B1: Discharge Checklist: child/young person with complex needs/NIV. Available from: https://www.wellchild.org.uk/wp-content/uploads/2021/07/Appendix-B1-Discharge-Checklist-CYP-with-complex-needs-NIV.pdf (Accessed 28/08/22)
  9. ↑ 9.0 9.1 9.2 Waring J, Marshall F, Bishop S, et al. An ethnographic study of knowledge sharing across the boundaries between care processes, services and organisations: the contributions to ‘safe’ hospital discharge. Southampton (UK): NIHR Journals Library; 2014 Sep. (Health Services and Delivery Research, No. 2.29.) Chapter 4, Discharge planning and care transition. Available from: https://www.ncbi.nlm.nih.gov/books/NBK259993/
  10. ↑ 10.0 10.1 10.2 10.3 10.4 East London Health & Care Partnership. Roles and responsibilities in discharge planning. xAvailable from:https://www.eastlondonhcp.nhs.uk/downloads/ourplans/Children/Professionals/Discharge%20roles%20and%20responsibilities.pdf (Accessed 28/08/22)
  11. ↑ 11.0 11.1 11.2 11.3 Enhance OT. Discharge Planning OT Services. Available from: https://enhanceot.com.au/discharge-planning-ot-services (Accessed 27/08/2022)
  12. ↑ Nunes HJ, Queirós PJ. Patient with stroke: hospital discharge planning, functionality and quality of life. Rev Bras Enferm. 2017 Apr;70(2):415-423.
  13. ↑ 13.0 13.1 13.2 Aphasia Pathway. Discharge Planning. Available from: http://www.aphasiapathway.com.au/?name=Discharge-planning#:~:text=Speech%20pathologists%20should%20be%20part,with%20the%20receiving%20healthcare%20providers. (Accessed 27/08/2022)
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