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

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== Introduction ==
== Introduction ==
Successful [[Discharge Planning|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.<ref>Henke RM, Karaca Z, Jackson P, Marder WD, Wong HS. [https://pubmed.ncbi.nlm.nih.gov/27147642/ Discharge Planning and Hospital Readmissions]. Med Care Res Rev. 2017 Jun;74(3):345-368</ref> <ref>Gonçalves-Bradley DC, Lannin NA, Clemson LM, Cameron ID, Shepperd S. [https://pubmed.ncbi.nlm.nih.gov/26816297/ Discharge planning from hospital]. Cochrane Database Syst Rev. 2016 Jan 27;2016(1)</ref>  This reduces the risk of elective procedures being cancelled or patient being held in emergency departments or waiting in corridors.<ref name=":0">Ibrahim H, Harhara T, Athar S, Nair SC, Kamour AM. [https://www.dovepress.com/multi-disciplinary-discharge-coordination-team-to-overcome-discharge-b-peer-reviewed-fulltext-article-RMHP 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.</ref> Moreover, by reducing length of stay in hospital there is reduced the risk of [[Hospital Acquired Pneumonia|hospital acquired infections]], medication errors, [[Thrombosis|thrombotic events]], [[Pressure Ulcers|pressure ulcers]], cognitive or functional decline.<ref name=":0" />
Successful [[Discharge Planning|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.<ref>Henke RM, Karaca Z, Jackson P, Marder WD, Wong HS. [https://pubmed.ncbi.nlm.nih.gov/27147642/ Discharge Planning and Hospital Readmissions]. Med Care Res Rev. 2017 Jun;74(3):345-368</ref> <ref>Gonçalves-Bradley DC, Lannin NA, Clemson LM, Cameron ID, Shepperd S. [https://pubmed.ncbi.nlm.nih.gov/26816297/ Discharge planning from hospital]. Cochrane Database Syst Rev. 2016 Jan 27;2016(1)</ref>  This reduces the risk of elective procedures being cancelled or patients being held in emergency departments or waiting in corridors.<ref name=":0">Ibrahim H, Harhara T, Athar S, Nair SC, Kamour AM. [https://www.dovepress.com/multi-disciplinary-discharge-coordination-team-to-overcome-discharge-b-peer-reviewed-fulltext-article-RMHP 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.</ref> Moreover, by reducing length of stay in hospital there is reduced the risk of [[Hospital Acquired Pneumonia|hospital acquired infections]], medication errors, [[Thrombosis|thrombotic events]], [[Pressure Ulcers|pressure ulcers]], cognitive or functional decline.<ref name=":0" />


[[Multidisciplinary Team|Multidisciplinary]] collaboration promotes effective discharge planning.<ref>Patel H, Yirdaw E, Yu A, Slater L, Perica K, Pierce RG, Amaro C, Jones CD. [https://pubmed.ncbi.nlm.nih.gov/30688821/ Improving Early Discharge Using a Team-Based Structure for Discharge Multidisciplinary Rounds]. Prof Case Manag. 2019 Mar/Apr;24(2):83-89.</ref>  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.<ref>Carroll A, Dowling M. [https://pubmed.ncbi.nlm.nih.gov/17851351/ Discharge planning: communication, education and patient participation.] Br J Nurs. 2007 Jul 26-Aug 8;16(14):882-6</ref>
[[Multidisciplinary Team|Multidisciplinary]] collaboration promotes effective discharge planning.<ref>Patel H, Yirdaw E, Yu A, Slater L, Perica K, Pierce RG, Amaro C, Jones CD. [https://pubmed.ncbi.nlm.nih.gov/30688821/ Improving Early Discharge Using a Team-Based Structure for Discharge Multidisciplinary Rounds]. Prof Case Manag. 2019 Mar/Apr;24(2):83-89.</ref>  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.<ref>Carroll A, Dowling M. [https://pubmed.ncbi.nlm.nih.gov/17851351/ Discharge planning: communication, education and patient participation.] Br J Nurs. 2007 Jul 26-Aug 8;16(14):882-6</ref>
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* Management advice. <ref name=":2" />
* Management advice. <ref name=":2" />
* Equipment prescription and provision.<ref name=":7">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 name=":7">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 onward referrals.<ref name=":2" />
* 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/
* 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/
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* 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>
* 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" />
* 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" />
* Onward referrals. <ref name=":6" />
* May need to organize family meetings. <ref name=":4" />
* May need to organize family meetings. <ref name=":4" />


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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 patients 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 onward 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]
  • Onward referrals. [13]
  • May need to organize family meetings. [9]

Doctor[edit | edit source]

  • Refer patients to other members of the multidisciplinary team as required. [14]
  • Refer patients to other specialties as required. [15]
  • Ensure patients can follow discharge instructions.[16]
  • Communicate with patient and family regarding estimated discharge date and answer any questions.[17]
  • Schedule any required tests or procedures early to prevent delays. [3]
  • Deem when the patient is medically fit for discharge.[10]
  • Prescribe medicines for discharge.[10]
  • Complete discharge summary.[10]

Nurse[edit | edit source]

  • Start planning early; planning can be aided by screening tools, risk assessment or care pathway.[18]
  • Identify whether patients with complex discharge needs. [18]
  • Identify who is taking the role of discharge coordinator, as it is different between hospitals/wards. [18]
  • Ongoing review of clinical management plan. [18]
  • Communication with patient and their family. [18]
  • Use a discharge checklist 24-48 hours before transfer/ discharge. [19]
  • Arrange and partake in multidisciplinary meetings. [10][20]
  • Foster understanding between the MDT of the different roles to improve accountability and referral processes. [18]
  • Arrange transport home. [8]

Discharge Coordinator[edit | edit source]

  • Lead in planning and coordination patients’ discharge. [21]
  • Ensure the clinical, social and care needs of a patient have been assessed and met. [22]
  • Establishing patient and family expectations. [22]
  • Confirm the MDT to understand each disciplines roles and responsibilities in discharge planning. [22]
  • Share knowledge of available services in the community or at home. [22]

Social Worker[edit | edit source]

  • Assess the patients’ needs as well as their home and financial circumstances. [9]
  • Arrange a package of care if required. [9]
  • May act as a key worker or case manager. [23][24]
  • Involvement for elderly patients with more complex cases or if there are difficulties with discharge destination placing. [25]
  • Discharge planning policy making. [24]
  • Patient and family counseling and advocacy .[23][24]
  • Supporting strategies for community reintegration. [23]

Pharmacist[edit | edit source]

  • Giving pharmacotherapy recommendations .[26]
  • Identifying and correcting discharge medication discrepancies. [27]
  • Dispensing discharge medicines. [26]
  • Teaching patients and their caregivers about the medicines. [26]

Psychologist[edit | edit source]

  • Assessment of patient’s needs,  for symptom stabilization and treatment planning. [28]
  • Liaison with patients’ family. [29]
  • Referral to community services. [29][30]
  • Utilizing published discharge planning checklists. [29]

Dietitian[edit | edit source]

  • Identifying patients at risk for nutrition problems or who may require more support. [31]
  • Referrals to community dietitian, either in a clinic or for home visits. [32]
  • Prescribing oral nutritional supplements for discharge.[32]
  • Education for meeting nutritional needs at home, including meal delivery programs. [32]

Conclusion[edit | edit source]

Resources[edit | edit source]

'IDEAL' Discharge planning checklist

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 3.2 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. ↑ 8.0 8.1 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 9.3 9.4 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/
  10. ↑ 10.0 10.1 10.2 10.3 10.4 10.5 10.6 10.7 10.8 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)
  14. ↑ Hegarty C, Buckley C, Forrest R, Marshall B. Discharge Planning: Screening Older Patients for Multidisciplinary Team Referral. Int J Integr Care. 2016 Oct 10;16(4):1
  15. ↑ Ragavan MV, Svec D, Shieh L. Barriers to timely discharge from the general medicine service at an academic teaching hospital. Postgrad Med J. 2017 Sep;93(1103):528-533.
  16. ↑ Patel PR, Bechmann S. Discharge Planning. 2022 Apr 5. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022
  17. ↑ New PW, McDougall KE, Scroggie CP. Improving discharge planning communication between hospitals and patients. Intern Med J. 2016 Jan;46(1):57-62.
  18. ↑ 18.0 18.1 18.2 18.3 18.4 18.5 Nursing Times. The key principles of effective discharge planning. 2013. Vol 109 No 3
  19. ↑ Department of Health. Ready to go? Available from: https://www.sheffieldmca.org.uk/UserFiles/File/Ward_Collab/Ward_Principles/Ready_to_Go_Hospital_Discharge_Planning.pdf (Accessed 29/08/2022)
  20. ↑ Goldman J, MacMillan K, Kitto S, Wu R, Silver I, Reeves S. Bedside nurses' roles in discharge collaboration in general internal medicine: Disconnected, disempowered and devalued? Nurs Inq. 2018 Jul;25(3):e12236
  21. ↑ Houghton A, Bowling A, Clarke KD, Hopkins AP, Jones I. Does a dedicated discharge coordinator improve the quality of hospital discharge? Qual Health Care. 1996 Jun;5(2):89-96
  22. ↑ 22.0 22.1 22.2 22.3 Zurlo A, Zuliani G. Management of care transition and hospital discharge. Aging Clin Exp Res. 2018 Mar;30(3):263-270
  23. ↑ 23.0 23.1 23.2 Abrams TE. Exploring the role of social work in U.S. burn centers. Soc Work Health Care. 2020 Jan;59(1):61-73.
  24. ↑ 24.0 24.1 24.2 Holliman D, Dziegielewski SF, Teare R. Differences and similarities between social work and nurse discharge planners. Health Soc Work. 2003 Aug;28(3):224-31.
  25. ↑ Auerbach C, Mason SE, Heft Laporte H. Evidence that supports the value of social work in hospitals. Soc Work Health Care. 2007;44(4):17-32
  26. ↑ 26.0 26.1 26.2 Li H, Guffey W, Honeycutt L, Pasquale T, Rozario NL, Veverka A. Incorporating a Pharmacist Into the Discharge Process: A Unit-Based Transitions of Care Pilot. Hosp Pharm. 2016 Oct;51(9):744-751.
  27. ↑ Walker PC, Bernstein SJ, Jones JNT, et al. Impact of a Pharmacist-Facilitated Hospital Discharge Program: A Quasi-Experimental Study. Arch Intern Med. 2009;169(21):2003–2010.
  28. ↑ Xiao S, Tourangeau A, Widger K, Berta W. Discharge planning in mental healthcare settings: A review and concept analysis. Int J Ment Health Nurs. 2019 Aug;28(4):816-832
  29. ↑ 29.0 29.1 29.2 Gowda M, Gajera G, Srinivasa P, Ameen S. Discharge planning and Mental Healthcare Act 2017. Indian J Psychiatry. 2019 Apr;61(Suppl 4):S706-S709.
  30. ↑ Hsiung DY, Lin EC, Lin KP, Lee MC. [Discharge planning: practical implementation in psychiatric care]. Hu Li Za Zhi. 2010 Apr;57(2 Suppl):S58-64
  31. ↑ Gordons Food Service. Nutrition's Vital Role in Discharge Planning. Available from: https://www.gfs.com/en-us/ideas/nutrition%E2%80%99s-vital-role-in-discharge-planning#:~:text=A%20dietitian%20or%20other%20food,require%20more%20care%20and%20attention (Accessed 29/08/2022)
  32. ↑ 32.0 32.1 32.2 Laur C, Curtis L, Dubin J, McNicholl T, Valaitis R, Douglas P, Bell J, Bernier P, Keller H. Nutrition Care after Discharge from Hospital: An Exploratory Analysis from the More-2-Eat Study. Healthcare (Basel). 2018 Jan 20;6(1):9
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