When considering Skilled Nursing Centers, you may have heard the term interdisciplinary care. Older adults entering Short-Term Rehab or Skilled Nursing after a hospital stay often have multiple medications and complex medical needs to manage along with therapy needs. Interdisciplinary care keeps all of their providers informed about your loved one’s full health picture with the goal of a safer discharge and fewer complications.
Key Takeaways: Interdisciplinary Care at a Glance
- Interdisciplinary care in Skilled Nursing and Short-Term Rehab is when different types of providers work as a team to coordinate care and create a safe discharge plan.
- Skilled Nursing Centers use interdisciplinary teams and include residents and family members in care and discharge planning.
- Interdisciplinary care helps prevent team members from making treatment decisions in isolation that could interfere with other treatments.
- Our interdisciplinary team meets daily, so the team stays informed between care and discharge planning sessions.
Table of Contents
What Is Interdisciplinary Care in Skilled Nursing?
How Interdisciplinary Care Coordination Works
The Interdisciplinary Team at The Healthcare Center at Buck Creek
What Is Interdisciplinary Care in Skilled Nursing?
Interdisciplinary care is a team approach that brings providers from different disciplines together for care coordination and discharge planning. The Centers for Medicare and Medicaid Services (CMS) require Skilled Nursing Centers to use interdisciplinary care teams consisting of providers who directly participate in your loved one’s care, including:
- The attending physician
- A registered nurse
- A certified nursing assistant
- A food and nutrition team member
- Any other practitioner that plays a role in care, as appropriate
Residents have a right to participate in care planning, and Skilled Nursing Centers are required to give advance notice so residents and their families can attend.
How Interdisciplinary Care Coordination Works
Interdisciplinary care means your loved one receives a unified care plan with input from all the center’s providers instead of treatment prescribed in isolation. It helps prevent prescriptions or treatments that interfere with each other. Each provider stays informed of changes. If a test result or progress note affects the discharge date or the type of treatment needed, the entire team knows. For example:
- An attending physician orders a swallow study, and the results suggest a change is needed in diet texture and how your loved one receives medication. Speech therapy, the dietary department, and the nursing team adjust care accordingly.
- The nursing team observes more pain and stiffness than anticipated during joint replacement recovery and informs the attending physician and physical therapy. The attending physician adjusts pain medication, and the physical therapist modifies the therapy pace.
- A CNA notices a wound healing more slowly than expected, so the wound care team member updates the treatment plan, and the case manager reassesses the discharge options and date.
For your family, an interdisciplinary team means you don’t have to worry about reporting every change to multiple providers. They’re already communicating with each other, so what one provider learns reaches the others.
Discharge Planning with an Interdisciplinary Team
Skilled Nursing Centers are required to involve the interdisciplinary team and the resident or Rehab Guest in the plan for when your loved one leaves Skilled Nursing or Short-Term Rehab, where they go, and what support they receive after discharge. This is known as the discharge plan. Your loved one also has a right to participate and include you.
The CMS regulations require the team to consider your family’s ability to provide necessary care and support after discharge. For example, if everyone in the family works, no one may be available during the day to help with wheelchair transfers. This could change treatment goals to require independent transfers, so the team adjusts the discharge date.
The Interdisciplinary Team at The Healthcare Center at Buck Creek
Every Skilled Nursing Center is required to have an interdisciplinary team, but how often the team meets is up to each center. At Buck Creek, our team meets daily to discuss treatment goals and progress between care planning meetings, not just leading up to them. When it’s time to update the care plan or plan for discharge, the entire team already knows where your loved one stands.
We’re here for you every step of the way. Schedule a tour today to meet the team and learn more about how we coordinate care.