St. Mary’s Medical Center Strengthens Discharge Process

St. Mary’s Medical Center in Maine has had much success with its multidisciplinary discharge planning at the bedside. The TCAB unit aimed to strengthen team vitality and increase patient satisfaction by involving the entire care team as well as the patient in rounds and discharge planning. They collaborated with the chief hospitalist to develop a method for involving the patient and family in discharge planning. The care team includes the charge nurse, patient’s nurse, physician, case management, social worker, physical therapist or occupational therapist, and pastoral care team representative. With each patient, the primary nurse gives a one-minute presentation followed by input from the care team, including the patient. This approach is a shift from traditional discharge planning, which occurs behind closed doors without patient input or opportunities for shared learning among the care team. According to Tammy Joly, RN, BSN, “…Patients have appreciated the involvement in their plan of care. It also gives them additional opportunity to understand the diagnosis they are dealing with and the collaboration amongst all providers about them.” In fact, a patient survey revealed that the majority of patients felt not only that they were given an opportunity to participate, but also that they had a role in their plan of care, without being intimidated by the number of staff at the bedside or confused by information presented. The TCAB team agrees that their process for multidisciplinary discharge planning at the bedside has resulted in insight, collaboration, trust, and the “invaluable gift of time.”