Interdisciplinary Professional Teamwork for Better Outcomes

1. Looking at the Big Picture: Discharge Referral Information

In the era of electronic discharge referrals, sometimes only the medically focused discharge information gets transmitted. As a result, the other areas of patient need are not discovered until the initial assessment. This chapter covers the critical areas of assessment and how to identify the other disciplines or services needed to meet the identified needs.

2. The Universe of Vendors

Clients and patients may not understand or may underestimate their needs until they or their families are overwhelmed or in crisis. Nurses and therapists are expected to holistically assess more than medical issues. This chapter covers practical ways of determining which professions, non-medical organizations, and benefit programs can address some of the identified areas of concern.

3. What’s the Difference Between Social Work, Discharge Case Management and Care Management?

Due to the pressure to discharge rapidly, sometimes only medical issues may be addressed by the hospital case managers. Thus, efforts such as empowering the agency social work staff to be the focal point for interdisciplinary coordination becomes crucial in creating a total care plan that reduces the risk of rehospitalization. Geriatric care managers may also be involved in overall patient and client management. Coordinating with private duty providers who are reliable and share the referring organizations commitment to excellence brings a wider resource net for patients and families. Interacting with private duty or other resources may also pose problems, especially when collaborators are not managed or coordinated by clinical professionals.

4. One Big Happy Family: Working Together for Success

The positive effect of having a team that works and communicates well impacts clinical outcomes. When a bigger picture is presented and there is access to a wider range of trusted vendors, your interdisciplinary team grows. In this way your patients and clients receive improved coordinated care. The structure of the effective interdisciplinary team is also addressed.