Roles of the Multidisciplinary Team in Discharge Planning from Hospital

Original Editor - User:Chloe Waller Top Contributors - Chloe Waller and Kim Jackson Top Contributors - Chloe Waller and Kim Jackson  

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 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]

Multidisciplinary Team.jpg

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 / walking aid 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 the 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 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]
  • District Nurse referrals. [21]
  • Foster understanding between the MDT of the different roles to improve accountability and referral processes. [18]
  • Arrange patient transport. [8]

Discharge Coordinator[edit | edit source]

  • Lead in planning and coordination of patient discharge. [22]
  • Ensure the clinical, social and care needs of a patient have been assessed and met. [23]
  • Establishing patient and family expectations. [23]
  • Educate the MDT to improve understanding of each disciplines roles and responsibilities in discharge planning. [23]
  • Share knowledge of available services in the community or at home. [23]

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. [24][25]
  • Involvement for elderly patients with more complex cases or if there are difficulties with discharge destination placing. [26]
  • Discharge planning policy making. [25]
  • Patient and family counseling and advocacy .[24][25]
  • Supporting strategies for community reintegration. [24]

Pharmacist[edit | edit source]

  • Giving pharmacotherapy recommendations .[27]
  • Identifying and correcting discharge medication discrepancies. [28]
  • Dispensing discharge medicines. [27]
  • Teaching patients and their caregivers about the medicines. [27]

Psychologist[edit | edit source]

  • Assessment of patient’s needs, for symptom stabilization and treatment planning. [29]
  • Liaison with patients’ family. [30]
  • Referral to community services. [30][31]
  • Utilizing published discharge planning checklists. [30]

Dietitian[edit | edit source]

  • Identifying patients at risk for nutrition problems or who may require more support. [32]
  • Referrals to community dietitian, either in a clinic or for home visits. [33]
  • Prescribing oral nutritional supplements for discharge.[33]
  • Education for meeting nutritional needs at home, including meal delivery programs. [33]
Healthcare Team.webp

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 . [21]

Example case study of MDT working:

[34]

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. ↑ 21.0 21.1 NHS England. Adoption of a new pandemic Multi-Disciplinary team (MDT) approach to discharge planning. Available from: https://www.england.nhs.uk/nursingmidwifery/shared-governance-and-collective-leadership/nursing-covid-19-catalogue-of-change/adoption-of-a-new-pandemic-multi-disciplinary-team-mdt-approach-to-discharge-planning/ (Accessed 29/08/2022)
  22. ↑ 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
  23. ↑ 23.0 23.1 23.2 23.3 Zurlo A, Zuliani G. Management of care transition and hospital discharge. Aging Clin Exp Res. 2018 Mar;30(3):263-270
  24. ↑ 24.0 24.1 24.2 Abrams TE. Exploring the role of social work in U.S. burn centers. Soc Work Health Care. 2020 Jan;59(1):61-73.
  25. ↑ 25.0 25.1 25.2 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.
  26. ↑ 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
  27. ↑ 27.0 27.1 27.2 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.
  28. ↑ 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.
  29. ↑ 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
  30. ↑ 30.0 30.1 30.2 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.
  31. ↑ 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
  32. ↑ 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)
  33. ↑ 33.0 33.1 33.2 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
  34. ↑ Donald W. Reynolds. Interdisciplinary Team Care: Case 1. Available from: https://m.youtube.com/watch?v=bYDuzL5zUL0&feature=emb_logo
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