John Loehner, MD
Matthew Berger, MD
Montefiore Medical Center provides care for a widely diverse patient population. Many patients require extensive discharge planning, often including complex social and ethical issues.
Patients’ needs, concerns, and requests challenge the discharge planning process, and team collaboration in decision-making is critical for quality outcomes. Interdisciplinary team (IDT) rounds are conducted daily on some of Montefiore's inpatient unitis to maintain high patient satisfaction through quality outcomes; provide safe, efficient, effective, and timely discharges; and to contain cost while maintaining service excellence.
Montefiore’s social workers serve an integral role in patients’ discharge planning, completing paperwork and coordinating related services (e.g., home care) to ensure a smooth post-hospital transition. Formerly assigned to specific clinical units, social workers were realigned to effectively partner with physicians and nurses and participate in IDTs rounds, conducted daily throughout the hospital to provide safe, efficient, effective, and timely discharges; maintain high patient satisfaction through quality outcomes; and contain cost while maintaining service excellence.
Each morning, a team of physicians, nurses, and social workers meets to review charts and visit patients scheduled for discharge that day. Advance notice allows patients time to mentally prepare to leave the hospital. This conscious anticipation of the length of the patient’s stay (known as clinical course) is also helpful for social workers and nursing staff.
Discussions with each patient help the team identify that patient’s needs and preferences. Each patient’s situation is discussed in a concerned, compassionate manner, and concrete, effective discharge plans are formulated with the same care and consideration that would be given to a family member or cherished friend.
Discharge plans include:
- appropriate consult referrals for nutrition counseling, psychiatric care, palliative care, diabetes care, substance abuse treatment, dialysis placements, early patient and family education, transportation arrangements for acute and subacute care, etc.
- patient activity plans: physical/occupational therapy, rehabilitation
- possible interventions and action plans for patients with barriers including homelessness, insurance issues, and challenging families
Team members are aware of their responsibilities and are held accountable to follow through with the plans for each of their patients. Throughout the day, team members continue to collaborate in communicating patient updates, transportation arrangements, education follow-up, consults, and other referrals.
IDT rounds also provide a teaching and learning forum for newly hired and seasoned nurses, healthcare providers, and college students rotating through units to gain clinical experience.