Improving Interdisciplinary Communication in Discharge Planning

Key Elements of Effective Communication

The American Heart Association recommends implementing a formal interdisciplinary care plan for each patient that clearly outlines roles and responsibilities of all team members, including attending physicians and physical therapists 1
The American Stroke Association suggests designating a discharge coordinator or case manager to facilitate communication between attending physicians, physical therapists, and other healthcare providers 2
The American Diabetes Association recommends developing standardized documentation templates that capture essential information from both attending physicians and physical therapists regarding functional status, mobility needs, and discharge recommendations 2
The American Stroke Association recommends implementing structured discharge communication tools that ensure timely and effective transfer of relevant patient information between attending physicians and physical therapists 2
The American Stroke Association suggests beginning discharge planning at admission with input from both attending physicians and physical therapists 2
The American Stroke Association recommends conducting pre-discharge assessments that incorporate both medical and functional perspectives 2

The American Diabetes Association recommends creating a standardized discharge checklist that includes input requirements from both attending physicians and physical therapists 3
The American Diabetes Association suggests developing clear protocols for handoff communication between inpatient and outpatient providers, including physical therapy needs 3
The American Stroke Association recommends establishing feedback mechanisms to continuously improve the discharge planning process 2

The Society of Critical Care Medicine recommends providing interprofessional education and training on effective communication techniques 1
The Society of Critical Care Medicine suggests conducting regular debriefing sessions following difficult discharges to identify communication breakdowns and opportunities for improvement 1

Regular scheduled patient selection conferences attended by all MDT members provide a venue where patient-specific data can be formally presented and discussed, synthesizing expertise from each discipline into patient-specific recommendations, as recommended by the American College of Cardiology 4
Beginning discharge planning at admission with input from both physicians and physical therapists establishes early collaboration, according to the American Heart Association/American Stroke Association 5

Ensure all team members (physicians, physical therapists, nurses, case managers, social workers) participate in discharge planning conferences, as suggested by the American Heart Association/American Stroke Association 5, 6
Conduct regular debriefing sessions following difficult discharges to identify communication breakdowns and opportunities for improvement, as recommended by the American College of Cardiology 4
Create a preprocedure briefing model where all team members discuss the intended procedure, specific tools needed, possible complications, and contingency plans, as recommended by the American College of Cardiology 4
Establish a private setting for MDT meetings to ensure focused discussion about patient care needs, as suggested by the Society of Critical Care Medicine 7