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Interprofessional teams in health care are considered to be one of the best approaches to improve patient outcomes. Interprofessional teams provide the means to integrate patient care with input from many different professional disciplines (Rose, 2011). Nurses are an important part of the interprofessional team, since they are often the team member that is closest to the patient (Miers & Pollard, 2009). I recently participated in a team that developed a work flow for daily readmission rounds. The team was interprofessional, the hospitalist, who was an APRN led the team. There was the case manager and the primary nurse who were both RN’s. The team also consisted of a resident, pharmacist, nutritionist, physical therapist, and social worker.
The team researched best practice for addressing readmission, and developed a checklist that evaluated the prior discharge plan and the potential gaps in care that contributed to the readmission. The team worked with the EHR analytics team to identify patients that had been readmitted to the hospital at 30, 60, and 90 days. An automated email sent a daily list of readmitted patients. The daily rounds were organized by the hospitalist who used of a checklist for each patient and led the discussion identifying gaps in care. In the lead role, the hospitalist APRN asked the questions, specific to each discipline. During the first few readmission rounds, I was impressed at the knowledge of the team members, especially the case manager and social worker and their knowledge of community resources. The resident, pharmacist, nutritionist, and physical therapist contributions were of great value and the team was able to assess the whole patient, not just one aspect of care. The primary RN was able to give insight regarding the patient’s story, the interactions with the family members and the patient’s cognitive ability to understand the plan of care. Working to develop the team was a worthy experience. We are now collecting data to evaluate if the rounds impact readmission rates.