Question

Planning for our patients during times of transitions (for example hospital to home, home to rehabilitation facility) involves collaboration with a number of healthcare professionals. Please address the following questions:

• How does your facility promote interprofessional collaboration during times of patient transitions?
• What is the role of the nurse inpatient transitions?
• What gaps can you identify in this process related to the quality of care? (If you are not currently in practice, please use a previous role or clinical experience in your answers.)

Answer 1

1.In medical circles, the term “clinical handover” is used to describe the transfer of care from one health care professional to another. However, the concept of clinical handover is limited in its capacity to capture the broad range of issues involved with the transfer of a patient and their care responsibilities from one part of the health care system to another. It is very focused on the role of the health care professional and does not acknowledge the role of the patient and their needs.

Providing the best hospital experience for patients requires coordination and communication between all providers involved in a patient’s care. This cooperative approach is referred to as interprofessional collaboration, and its goal is to help doctors and nurses work together to administer the highest quality care. Interprofessional collaboration fosters trust and respect between all healthcare providers and encourages the practice of treating nurses as equals with physicians. Multidisciplinary rounds offer a simple way to improve communication between departments. Nurses should encourage their staff to take advantage of these opportunities to ask questions, get clarification and discuss patient goals with other providers. Multidisciplinary rounds are a perfect example of interprofessional collaboration as they allow every team member to hold discussions and share crucial information about each patient’s plan of care. They ensure each provider is on the same page regarding what is best for the patient.

2.Nurses interact with patients/families at their most vulnerable times and often learn information critical to successful transition planning. They play a key role in promoting successful transitions by developing and evaluating the transition plan and identifying and communicating barriers to the plan. Examples of barriers include limited finances to cover out-of-pocket costs of PAC and family members who do not have the capacity to provide care post discharge. Communicating this information to the interprofessional team early in the patient’s hospital stay is essential to assure that the transition plan is tailored to the needs of the patient and family, and that patients are transferred to the appropriate PAC setting. The intensity of medical, nursing, therapy, and other services varies significantly along the care continuum from inpatient rehabilitation facilities to skilled nursing facilities to community-based care. To be most efficient and effective, care settings must be matched to patients’ needs to ensure optimal function and participation in meaningful activities and avoid costly readmissions. Comprehensive rehabilitation with adequate resources, dose, and duration must be provided to achieve these outcomes.This model illustrates matching the discharge environment and support with the patient’s required needs based on functional prognosis.